Hospital patient overdosed after twice gaining access to medicine store

Father-of-two Lewis Begley was an inpatient of Chatterton House, a mental health facility in King's Lynn, when he died in December 2020 at the age of 35.

An inquest into his death began on Monday and is due to last more than a week.

It heard that Mr Begley was found unresponsive in his bedroom at the site after having twice gained access to the hospital's medicine room in the hours leading up to his death.

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

CPR was performed on him but he could not be brought around and died in the hospital, which is run by the Norfolk and Suffolk NHS Foundation Trust (NSFT).

Giving evidence at the inquest, the man in charge of the hospital at the time admitted to having no knowledge of Mr Begley entering the medicine room until reviewing CCTV with the police after his death.

Luke Peak, who was acute service manager for West Norfolk at NSFT, told the inquest his first encounter with Mr Begley was when he performed CPR in his hospital bedroom after two staff members raised the alarm.

He said that he had not been made aware that Mr Begley had twice accessed the medicine room.

The inquest heard that the room was only meant to be entered by staff, via a door accessible only by wrist band and that medication was stored in locked cabinets, with keys also locked inside a secured case.

The court is yet to hear just how the bricklayer managed to enter the room.

Lewis Begley, who was 35 when he died

Mr Peak said that the medication room itself was not covered by the CCTV in the hospital as it was seen as a "low risk" area, because it was only accessed by staff.

Asked by senior coroner Jacqueline Lake if a record was kept of when medication was taken, he replied: "No."

He added that staff would be expected to report to management if a patient was found in the room.

Meanwhile, members of Mr Belgey's family told of his troubled past and shared their feelings of being let down by the care he received throughout his life.

His mother, Sheila Begley, said that at a young age her son had "fallen in with a crowd of older boys" who involved him with crime and he was "made an example of", leading to him serving time in a juvenile detention centre. She said he was "never the same when he came back".

Throughout his life, he fought mental health issues which saw him tormented by voices and would turn to alcohol and drugs to try and suppress these.

Chatterton House is getting a new ward, with a local name. Samphire Ward. Photo: NSFT (Image: NSFT)

She said: "He very much wanted to lead a normal life but never got the right support."

Natasha Morrison, his sister, told the court: "He always stuck up for other people and when they got in trouble he was a loving friend - but he was never able to take the advice he was giving out."

She said his mental health deteriorated to the point that he was regularly hearing voices and that the family pleaded for him to be assessed under the Mental Health Act.

She added: "It reached the point where we worried for our own safety, his safety and the safety of others - but our pleas for help were rebuffed every time.

"It felt as though he was too unwell to be able to ask for help himself but not unwell enough for it to be forced upon him."

Eventually, he was assessed after being arrested in Great Yarmouth on suspicion of a serious assault on a woman and admitted to Chatterton House on December 12.

In the weeks leading up to this, he had been staying in Bishops Bridge House, which is run by St Martin's Housing Trust and had also spent time staying at his parents' in Blofield.

The inquest continues.