An NHS trust has brought in a new chief pharmacist following the death of a patient who broke into one of its medical stores.

Lewis Begley died in December 2020 after a spell as an in-patient at Chatterton House in King's Lynn.

During this time, Mr Begley managed to twice gain access to the mental health facility's medical store and was found unresponsive in his bedroom hours later.

An inquest into his death held earlier this year found that he had suffered neglect in his treatment and senior coroner Jacqueline Lake outlined her concerns in a report to prevent future deaths (PFD).

Responding to her concerns, the Norfolk and Suffolk NHS Foundation Trust's chief executive revealed that as a result of the case the trust had employed a new chief pharmacist to oversee its approach to medication.

In a written reply to the PFD report, Stuart Richardson wrote: "We have recently employed a new chief pharmacist in the trust who has already begun improvement work in this area."

He said the new chief pharmacist had revised the trust's medicines management policy and that auditing medication will now be led by its pharmacy department.

He wrote: "This is a change in process and accountability and will address the issues of stock oversight in ward areas."

The coroner stated in her report that she was concerned that the record-keeping at Chatterton House meant that staff at the site had no way of knowing what medication Mr Begley had managed to smuggle out and in what quantity.

Mr Richardson added: "The sad death of Lewis was not anticipated, however, we apologise that we did not have the robust systems in place at that time which would have enabled staff to ascertain what and how much medication he had required.

"It is anticipated that in light of the chief pharmacist's improvement plan our medication management systems will meet the necessary safety levels in the future providing confidence and resilience for all."

Mr Begley was admitted to Chatterton House on December 11, 2020, after being detained under the Mental Health Act.

He died on the morning of December 15 at the age of 35.