Tŷ Llywelyn: Mental health patient died of sepsis - inquest

Darren Roberts-Pomeroy died at Tŷ Llywelyn medium secure mental health unit in Llanfairfechan, Conwy

A mental health patient died of sepsis after he became constipated due to schizophrenia medication, an inquest has heard.

Darren Roberts-Pomeroy, 24, was found dead in his bed at the Tŷ Llewelyn medium secure unit in Llanfairfechan, Conwy county, in October 2021.

Opening the inquest, the coroner heard there were several concerns about his care raised in an independent review.

Mr Roberts-Pomeroy's family said they were considering legal action.

Roberts-Pomeroy, from Conwy, was jailed along with another man for three years and four months after admitting robbery in July 2018.

Senior coroner John Gittins heard he had served his sentence and was on licence but had been detained under the Mental Health Act.

Mr Gittins said pathologist Dr Brian Rodgers had given a provisional cause of death as sepsis due to toxic megacolon caused by constipation induced by clozapine, a medication prescribed for schizophrenia.

After Mr Roberts-Pomeroy's death, Betsi Cadwaladr health board commissioned an independent review.

Max Saffman KC, representing Mr Roberts-Pomeroy's family, said there were several concerns about his care and treatment at Ty Llŷwelyn, on the Bryn y Neuadd Hospital site.

Ty Llŷwelyn is a 25-bed unit on the grounds of Bryn y Neuadd Hospital

One issue was the level of observation by staff in the hours leading up to his death when his condition deteriorated.

Mr Gittins said he had seen evidence staff had observed him through a "porthole" in the door instead of entering his room.

"I am aware that there has been an external report undertaken at the behest of the health board into the care and treatment he received, and that highlighted a number of matters," he said.

Mr Saffman told the hearing in Ruthin, Denbighshire, the family was considering legal action.

The coroner said he intended to ask an independent expert to examine his care, including the prescribing and monitoring of clozapine and to express an opinion on whether there may have been a different outcome if he had been seen sooner.

The full inquest is expected to be held later this year and last three days.