“During the course of the inquest I heard evidence that it was likely that Mr Davies had…”

The coroner’s concerns

– (1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am; (2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair; (3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence. (4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair. (5) The deceased was admitted to the Centre with a known substance abuse problem; (6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure; (7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use; (8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015. (9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants; (10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage; (11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken; (12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding. (13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area. (14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2020-0261

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0