Before Senior Coroner Jaqueline Lake, Norfolk Coroner’s Court
5 – 13 September 2022

Lewis Begley, 35, died on 15 December 2020 of central nervous system and respiratory depression, caused by combined drug toxicity. This followed Mr Begley having gained access to a medication room on the secure mental health unit he was detained on in the early hours of the morning.

Mr Begley then returned to his room, where he was maintained on hourly observations for the rest of the night. Mr Begley was not searched. Nor was his room. Nor was he reviewed by a medical practioner. He was found unresponsive in his bed later that morning. Ward staff and emergency services attempted CPR, but he was pronounced dead at the scene. 

Following Mr Begley’s death, CCTV confirmed that he had accessed the medication room twice that night: the first entry for a matter of seconds, and the second for a period of some 15 minutes. Further investigation identified faults with the installation and design of the lock mechanism to the door.

Shortly after Mr Begley’s death, numerous empty medication packages and blister packs, for medication which he was not prescribed, were found hidden in his room. The post-mortem also identified a package containing two different types of non-prescribed medication secreted within his body. The toxicological evidence detected various levels of different, non-prescribed medication within Mr Begley’s system which, together with the effects of his prescribed medication, was considered fatal.  

Concluding a seven-day inquest, the jury found that there were a host of failings in respect of the response to this incident, namely:  

• A failure to escalate the risk of having found Mr Begley alone in a room full of medication
• Consideration was not given to further safeguarding checks to ensure Mr Begley was safe after the incident
• There was a failure to follow multiple relevant policies and procedures, including those regarding observations, searching, and management of medications
• Inaccurate and inadequate information was passed on during handover to staff coming onto shift the following morning

Following from the above, the jury found that misadventure and neglect contributed to the cause of Mr Begley’s death.

Natasha Morrison, Lewis Begley’s sister, comments:

I am glad the inquest is over and short of getting Lewis back I don’t think we could have got a better outcome. Although it looks like a win – ultimately we have still lost. Lewis isn’t coming back and the ramifications for the family have been huge. I hope that Lewis’s death makes a difference and that real change can come from it.

Will Whitaker, solicitor at Bindmans LLP who represents Ms Morrison, said:

Lewis and his family trusted those charged with his care to look after him, and to help him out of crisis. They did not, and he was let down following fundamental failures to ensure that Lewis was safe and well. Simple steps could have been taken to determine whether Lewis had taken or ingested medication during or after being found in the medication room. The jury’s findings confirm that those steps were not taken and that those failings contributed to Lewis’s death. It is hoped that the Trust considers the jury’s finding of neglect very carefully to ensure that steps are taken so that this cannot happen to anyone else in future.

Mr Begley’s sister, Natasha Morrison, is represented by Will Whitaker of Bindmans LLP and Laura Profumo of Doughty Street Chambers.