STEFAN WALKER · Prevention of Future Deaths report

On 7 JULY 2020 the Senior Coroner commenced an investigation into the death of STEFAN WALKER aged 40 (hereafter “STEFAN”), who died on 29 June 2020.

The investigation concluded at the end of the inquest held between 20ᵗʰ and 28ᵗʰ May 2024.

The said investigation was one to which the enhanced investigative obligation, under Article 2 of the European Convention on Human Rights, applied.

The conclusion of the inquest jury was that STEFAN’S death was ‘Drug related’ – the medical cause of death being ‘buprenorphine and flualprazolam intoxication, and cardiac enlargement’ and that, inter alia, ‘Stefan died in his bedspace at Cefn Coed Hospital, Swansea on 29 June 2020 sometime between 1520 and 1545’.

(1) At the time of his death STEFAN was a detained patient under the Mental Health Act 1983 and receiving in-patient psychiatric treatment on Fendrod Ward on account of his diagnosis of polysubstance misuse, psychosis, Emotionally Unstable Personality Disorder, and ADHD.
(2) The evidence that I and the jury heard was to the effect that on both 28ᵗʰ and 29ᵗʰ June 2020 there were concerns that STEFAN had consumed illicit substances and was displaying symptoms of being physically unwell (overly sedated and drowsy, slurring his speech and tripping over his feet, unable to keep his eyes open and perspiring profusely). He disclosed to staff that he had taken ‘street diazepam’.
(3) In the afternoon of 29 June 2020 he was found unresponsive in his room and attempts were made by nursing staff and paramedics to resuscitate him. The evidence and the jury heard was that STEFAN was displaying no signs of life when he was found.
(4) Naloxone and Flumazenil were both administered by a junior doctor and the ward pharmacist with the assistance of the paramedics when they arrived – the Flumazenil only because it was kept on the ward. It was not carried by the paramedics, and I was told that it is not carried by paramedics.
(5) Toxicology after his death revealed the presence of both buprenorphine (strong opioid analgesic) and flualprazolam (novel designer benzodiazepine).
(6) Flumazenil is a potential antagonist in relation to the novel designer benzodiazepine.

(1) I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry naloxone). The availability of flumazenil was hampered in this case because STEFAN was on an acute psychiatric ward where the said antagonist was being kept and could be prescribed by the ward pharmacist and administered by the doctors (with the support paramedics when they arrived).
(2) I am concerned that there may be other acute circumstances when the use of this particular antagonist (flumazenil) could make a difference (say in the case of the collapse of person on the street or otherwise in the community) but will not be available since paramedics do not it.
(3) I and the jury heard no evidence as to why naloxone is carried, but other antagonists (such as flumazenil) not.