A man dies in hospital after the staff fail

The family of a man who died in his bed at a mental health hospital after staff failed to search for him and other patients in his ward say they are “devastated” by their loss – but are determined to make sure their beloved brother and son “shall not be in vain”.

The inquest into the death of Stefan Barrie Walker, heard at Swansea Coroners’ Court before deputy coroner Edward Ramsay and a jury of 10 members of the public, concluded on Tuesday 28 May. Swansea mid-afternoon on June, 29 2020 – and concluded that his death could have been avoided if hospital staff had searched him and other patients in his room after his return a short time away from the hospital.

An inquest into Mr Walker’s death was first opened on 7 July 2020 but was adjourned until 20 May 2024. On the first day of the reopened inquest, Swansea Coroners’ Court heard that the family of Mr. Walker will be remembered for his “larger than life personality” and “great personality,” and I have heard a detailed history of Mr. Walker’s mental health evaluation, as well as an account of how Mr. Walker has been under the medical care of Cefn Coed mental health hospital. You can also relive the first day of research started in the previous article here. For the latest Swansea news, subscribe to our newsletter here

RELATED NEWS: Two out of four children have been hurt in ‘mischievous’ accidents

SWANSEA: A health board explains how it has saved millions of pounds in nursing costs

After hearing evidence from medical experts and people involved in Mr. Walker’s care, deputy coroner Edward Ramsay officially closed the inquest into Mr. Walker’s death on Tuesday, May 28, 2024. Inquest report it gives Mr. Walker’s cause of death as “buprenorphine and flualprazolam”. intoxication and heart enlargement” and provides a general conclusion of drug-related mortality.

Explaining the circumstances of Mr Walker’s death, the record reads: “Stefan passed away at his bedside in Cefn Coed Hospital, Swansea on 29 June 2020 between 3.20pm and 3.45pm.” The additional statement explains further: “Stefan Barrie Walker’s death was caused by the effects of illegal substances combined with an enlarged heart. Stefan had health problems of the mind that was enhanced by his use of illegal substances.

“Staff’s knowledge of the illegal search policy was inadequate. Extended leave was given and there was still a sense of normalcy. A full health check A check-up was done on June 28, 2020 by a general practitioner. As a result of this check-up, observations were made at 15-minute intervals along with blood pressure and respiratory rate monitoring for for the next six hours. 28, 2020, therefore, no further measures were deemed necessary except to reduce the reaction time from 15 to 30 minutes.”

Some comments on the inquest report said that if staff had checked Mr Walker and others for drugs after he returned to the “floor space” away from the hospital premises, they had not. had done, Mr. Walker’s life would have been saved.

In the statement “Was there a mistake in carrying out a proper and lawful investigation of Stefan and others in Fendrod Ward at Cefn Coed Hospital for illegal activities after his return from leave on 28 June 2020, in the way that it might save his life,” the court said “Yes”.

However, in the question ‘Was there a failure to carry out a full health check on Stefan, including the well-read ‘NEWS’ information, prior to his death on 29 June 2020, in a way that could have saved his life,’ the court said “No”.

Family honors ‘larger than life’ Stefan Walker

Stefan Walker’s family have shared the following tribute with WalesOnline, through their legal representatives Harding Evans solicitors. Stefan Walker’s mother, Christina Clancy, and his siblings said: “Stefan Walker was our son and our brother. He was a great person with a great personality. Stefan is he was also complex and suffered from many mental health problems.

“On 29 June 2020, while under the care of Cefn Coed Hospital, a mental health facility in Swansea, where he was a resident patient, Stefan died of drink too much alcohol. During the inquest at Swansea Coroner’s Court, we heard of the failings of those with a duty of care to put steps in place which we feel could have prevented Stefan’s death

“Specifically, the investigation found that there was a failure to carry out a proper and lawful search of Stefan and others in Fendrod Ward in Cefn Coed for illegal items following his return from leave on 28 June 2020 in a way that could save his life.

“As a family, we have been left devastated and there is a huge hole in our lives. This should not have happened and if this investigation had been carried out, Stefan might be with us today. We were pleased to hear that Cefn Coed had undertaken an independent review and implemented a number of changes, sadly these came too late for Stefan.

“We are also concerned about the lack of mental health facilities. In Wales, there is only one facility that provides the type of treatment that Stefan needed and that is a private hospital. There is no provision to The NHS in Wales.

“We are determined that Stefan’s death was not in vain and we are determined to fight for treatment to be readily available, so that people get the right help and no other families need it more. what we have. We would like to extend our thanks to our legal team and to the case examiner.”