THE death of a man who died while on escorted leave from a mental health ward with a carer has been ruled misadventure by a jury.

Kevin Langley, 55, of Fishguard Road, died on September 28, 2018, while out on a walk around Withybush woods in Haverfordwest, while with a care worker.

A coroner’s court heard late last month that Mr Langley had been suffering from a psychotic illness for several years and previously received care in the community.

Introducing the case, the coroner Mark Layton, gave an overview of how Mr Langley died, he said: “At the time of his death, he was detained under the mental health act at Bro Cerwyn Ward at Withybush Hospital. He had made previous suicide attempts.

“On September 28, 2018, Mr Langley was allowed escorted leave, in the presence of a member of staff he went for a walk in Withybush Woods.

“During the course of the walk, Mr Langley told the staff member that as a child he would play a game whereby he would see how many stones he could fit in his pockets.

“Mr Langley filled his jacket with stones and when the staff member suggested they return to the minibus, Mr Langley pushed the staff member aside and ran into a pond.”

Western Telegraph:

Jeremy Davies the coroner’s officers for Dyfed-Powys Police said that Mr Langley had been allowed to walk in the area previously as part of his care plan.

Graham Jones, the care worker who was with him on the day, said in the period leading up to his death Mr Langley had been “displaying a lot of aggression” but seemed to be improving.

The court heard that Mr Langley’s mental state had taken a turn when he was taken off of clozapine – a drug used to treat schizophrenia, which requires users to have rest-periods if they show signs of the drug affecting the liver.

When Mr Langley’s blood test came back with a warning, he was taken off of clozapine, with the intention of starting the treatment again in the future.

After the warning, Mr Langley was placed on an alternative anti-schizophrenic medication.

Mr Langley had asked to go for a walk because it might help him clear his head after being on a busy ward.

Mr Langley’s family said he had always loved being outdoors, they said: “We would like to say Kevin loved the outdoors. He would not have liked being confined to the ward against his will.

“He was a reserved person, I can understand the need to go out, when he was a little more well he used hiking as a coping mechanism.”

When they got close to the pond, Mr Jones said he had tried to place himself between Mr Langley and the pond – which he said he did by instinct – suggesting they return to the minibus.

When Mr Langley ran into the pool of water, Mr Jones said he called the emergency services for help.

“I didn’t follow Mr Langley into the water because I know he had stones on him and knew he could be aggressive. I shouted to him I thought he could hear me, but I can’t be sure. “

The family of Mr Langley asked several questions surrounding the circumstances of his death. Mr Langley’s family questioned why he had been placed at Haverfordwest’s Bro Cerwyn ward when he lived in Carmarthen.

Expert witness Professor Gournay said there was a lack of space around the country and a patient may be placed away from home.

Prof Gournay added that because Haverfordwest is an acute ward it was deemed appropriate, with patients not often staying for extended periods.

Asked if a recent eviction could have contributed to his mental ill-health, Prof Gournay said he could only speculate.

The court also heard that sending more than one person out with a patient is not always effective, with some patients needing more space.

The coroner gave the jury three options for the conclusion they could return suicide, misadventure or an open verdict.

The jury deliberated 30 minutes before returning a conclusion of misadventure. Closing the case, Mr Layton offered the family his condolences.