Hearing Concludes With Verdict Of Neglect

The brother of a mental health patient who died after the Juniper Ward in Weston-Super-Mare failed to appropriately manage his medication regime, which included methadone, hopes that lessons are learned following an inquest into the death.

Abdelslam Benelghazi (known as Abs by his family), who had a diagnosis of schizoaffective disorder and a history of drug misuse, was found unconscious on 9 December 2017. Despite the efforts of staff and emergency services, he could not be revived and died aged 37.

An inquest held this week at Avon Coroners Court highlighted a number of concerns regarding the support that Abs received in the days prior to his death.

In particular the inquest heard evidence that there had been failures to follow guidelines regarding the management of his methadone, and that inadequate action was taken to respond to signs that Abs was becoming oversedated.

Dr Jon Barnes, an expert in adult addiction psychiatry gave evidence that when prescribing methadone, consideration should be given to the sedative effects of other drugs which the patient was also prescribed. He said that there were a number of red flags which should have alerted staff that Abs was becoming oversedated.

Now, after the hearing concluded with a verdict of neglect, Abs’ brother Samir Benelghazi has joined with specialist human rights lawyers at Irwin Mitchell in calling for lessons to be learned.

Expert Opinion

“This inquest has been a hugely emotional time for Samir and his family, as they have of course had to relive the chain of events which ultimately led to Abs’ death.

The hearing raised some very concerning issues regarding the management of the medication he was prescribed, and a failure to escalate signs that Abs was becoming oversedated.

Those who require mental health support and have drug dependencies are among the most vulnerable members of society and it is vital that every step is taken to learn lessons from the issues that we have heard at this inquest.”
Fiona McGhie - Partner

The jury concluded that the following factors contributed to Abs’ death:-

- Increasing the dosage of methadone beyond the normal limits set out in recognised guidance
- Continuing to prescribe clonazepam in conjunction with other opiates, without establishing the reason for the original prescription
- Failing to put in place an adequate pharmacological care plan to assess, monitor and review the patient and to communicate it to relevant staff
- The failure of the medical and nursing team to initiate any medical investigation or intervention for enhanced physical and non-contact observations.
- The failure to administer naloxone when Abs was found collapsed

Samir Benelghazi, 47, said: “The inquest has been incredibly difficult. Hearing about the events that unfolded in the lead up to my brother’s death has been particularly hard.

“However, it is something we had to do. Our family was determined to honour Abs’ memory by establishing the facts as to why he died.

“Nothing can bring my brother back and we will always be left wondering ‘what if?’"

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