'Missed opportunities' in Dudley hospital care to save man who took an illicit substance, inquest hears
An inquest into the death of a patient at a Dudley hospital who took an illicit substance has found there were missed opportunities in the care he received at hospital in the period leading up to his death.
William - 'Will' - Giles, aged 22 died from on August 23 2023 whilst an inpatient at Bushey Fields Hospital where he was receiving treatment for his mental health.
A three-day inquest at Black Country Coroners Court examined the care and treatment provided to Will including the adequacy of overnight observations, whether appropriate monitoring and management plans were in place for substance misuse, and the use of illicit substances on the ward.
It heard there was “no structured approach” for the risk management of substance misuse at the hospital and that opportunities for staff to detect contraband were missed.
HM Assistant Coroner Kelly Dixon also said the failure to complete observations from 5am onwards on 23 August 2023 was an omission in the patient's care and it was not acceptable for staff to record that the patient “appeared asleep” when they had been unable to establish whether he was breathing.
She also found he did not receive the standard of care expected and there were multiple instances during the early hours of the morning on which he died, where observations fell short as well as an absence of a substance misuse care plan.
