Neglect partly caused mental health patient's death

Neglect contributed to the death of a man in a mental health unit, an inquest jury has found.

Darren Roberts-Pomeroy, 24, was found dead in his bed at the Tŷ Llewelyn unit in Bryn y Neuadd Hospital in Llanfairfechan, Conwy county, on 1 October 2021.

He complained of stomach aches the day before and was due to have medical checks every four hours during the night, but they did not happen and security nurse Geraint Jones, who claimed to have visually checked on him hourly, was found to have given "dishonest" information.

Returning a narrative conclusion contributed to by neglect, the Ruthin inquest jury recorded "gross absence of care" after Roberts-Pomeroy's death from sepsis.

Roberts-Pomeroy, from Llandudno, was jailed for three years and four months for robbery in July 2018, but was transferred to Tŷ Llywelyn under the Mental Health Act.

He was treated for schizophrenia and was being prescribed Clozapine, a "gold standard" treatment but known side effects include constipation.

A pathologist found Roberts-Pomeroy died of sepsis caused by a toxic megacolon as a result of Clozapine-induced constipation.

Dr Brian Rogers, who carried out the post-mortem examination said he may have been dead for up to six hours before he was found at 09:40.

Roberts-Pomeroy first started complaining of stomach aches at lunchtime the day before his death.

Dr Laura Robbins said, when she checked about 13:00, she was not overly concerned about constipation because he had a bowel movement the previous night.

Nurse Jayne Bayliss and ward manager James Butterworth did medical checks at 19:50, but a faulty blood pressure machine meant they were not completed.

This meant Roberts-Pomeroy's care should have been escalated and screened for sepsis, but it was not.

Checks were repeated at 21:00 by overnight ward manager Claire Leady and security nurse Geraint Jones said in a statement that Roberts-Pomeroy was asleep at 22:00 and he claimed to have done hourly visual checks.

But Coroner John Gittins said CCTV footage proved this to be "untrue", adding that the health board had "taken action" and Mr Jones no longer worked there.

Expert witness Abhiram Sharma said if Roberts-Pomeroy had been monitored as he should and treatment provided, he would probably have survived.

The jury concluded staff failings included "an obvious failure to provide basic medical attention for Darren, insufficient monitoring... simple basic medical checks not carried out and inadequate communication of staff duties and responsibilities".

Roberts-Pomeroy's father Peter Pomeroy said his son was improving at the hospital and "felt happy" there, adding that he was "astounded" to know his son was not checked properly.

In a statement, the family said: "We finally feel as though we can start to move on having had some sort of closure for Darren's tragic and devastating passing."

Teresa Owen of the health board said: "We fully accept the jury's conclusions and will reflect further on them over the coming days."

She added that an independent investigation highlighted a number of recommendations that had been "accepted and actioned".