Hospital patient who died of overdose suffered neglect, jury finds

Lewis Begley died while being treated at Chatterton House in King's Lynn in December 2020 after being found unresponsive in his hospital bedroom.

On the seventh and final day of an inquest into his death, a jury concluded that "neglect" had played a part in the 35-year-old's death, while it ruled to be by "misadventure".

Mr Begley was admitted to the facility on December 11, 2020, having been arrested on suspicion of a serious assault and detained under the mental health act.

Lewis Begley, who died at Chatterton House in King's Lynn (Image: Begley Family)

His family, who had long fought for him to receive mental health treatment, were delighted to hear he had been admitted to the facility - believing he would finally receive the care they hoped for.

But just four days later, the father-of-two was dead, after being found unresponsive in his bedroom in the morning of December 15.

Hours earlier, he had managed to gain access to the hospital's medicine store, where he spent 15 minutes undetected.

He died due to central nervous system and respiratory depression, due to combined drug toxicity.

The inquest heard Norwich-born Mr Begley had twice gained access to the medicine room using a card to manipulate a faulty lock, which had not been installed correctly.

Earlier on, he had been seen "acting suspiciously" in a communal part of the site, but told staff he was simply "bored".

Lewis Begley, who died in a King's Lynn hospital after gaining access to its medicine room (Image: Begley Family)

Giving the jury's conclusion, its foreman said when Mr Begley was found in the store there was a "failure to escalate the risk" of the situation.

He added that "inadequate and inaccurate information" was passed by the nurse to colleagues during shift handover, which meant an appropriate response to the situation could not be carried out.

Mr Begley was discovered in the medicine room by then nurse Krishen Mooroogan, who did tell colleagues what had happened during a handover, but did not alert senior management.

Summing up Mr Mooroogan's evidence, senior coroner Jacqueline Lake said: "He said he did not feel he could raise concerns as it was not a supportive environment and that he felt paralysed working there."

Lucy Frost, a clinical director at the Norfolk and Suffolk NHS Foundation Trust, confirmed that Mr Mooroogan had since been dismissed from the trust.

Meanwhile, Mrs Lake raised a number of concerns around the treatment Mr Begley received and said she would be preparing two reports to prevent future deaths relating to the case.

She said one of these related to the way that the trust keeps track of what medication it has in its facilities.

Earlier in the inquest, the court was told by acute service manager Luke Peek, who was also in charge of the ward at the time, that no inventory was kept for certain medications.

Mrs Lake said she was also concerned to hear that hospital staff were not trained in administering a treatment which can reverse overdoses.

Following the inquest, Ben Begley, Mr Begley's father, said he was pleased with the conclusion the jury had reached.

Stuart Richardson, chief executive of NSFT, said: "We would like to offer our sincere condolences to Lewis’ family for their tragic loss.

“We carried out immediate remedial work to address the defective installation of the locking system. We also completed extensive internal investigations following Lewis’ death and have taken several steps as a result.

“We immediately suspended a staff member, who was subsequently dismissed and reported to the appropriate regulatory body.

"We have also taken actions to promote best practice, which includes strengthening medicines management processes across the trust.

"In addition, refresher training for staff has taken place around completing and recording therapeutic observations and resuscitation.

“We will now review the inquest findings to see whether there are any further steps we could take to prevent a similar incident from happening in the future.”

Police have not pursued any criminal prosecutions relating to the death.