A teenage boy found dead at an assisted living complex should have been checked on every hour but was not.
Noah Fall-Smith was found dead at Gwalia Pobl’s Foyer project in Swansea having taken a fatal overdose of drugs.
Staff left a handover note the day before recommending that there were regular checks on the 19-year-old, reports Wales Online.
But the note was not heeded until after his death on March 17 2016.
Assistant coroner Paul Bennett heard Mr Fall-Smith had been taking drugs since he was around 13 or 14 years old.
Despite being intelligent he achieved low GCSE grades and enrolled on a number of courses in Swansea but didn’t persevere with them. Instead he started leading a hippy lifestyle, choosing to grow his hair and smoke legal highs, the inquest heard.
As tensions rose at home with his family unhappy about his drug-taking Mr Fall-Smith moved out and into supported accommodation at The Foyer in 2015.
But he suffered from anxiety and depression, was self-harming, and regularly missed appointments with professionals trying to help him.
Detective Sergeant James Wilson, from South Wales Police , told the inquest in the run-up to his death Mr Fall-Smith went on a week-long drugs binge. He was described as taking more drugs than his friends in a bid to have a longer high.
On March 16, 2016, he was spotted by a staff member slumped near the main entrance to The Foyer. He told them he just needed to sleep as he hadn’t done so for two to three days. Although unsteady he made it to his room.
When asked if staff could check on him he agreed but, due to staff commitments, he wasn’t checked on even though one of the handover logs suggested hourly checks on him.
When a member of staff went the following to check he was attending a session that had been organised Mr Fall-Smith didn’t respond. When they returned 10 minutes later and went inside the room his skin was cold and an ambulance was called. Paramedics arrived and confirmed he had died.
Toxicology results showed hiss body contained morphine at a level that would be toxic even in experienced morphine users.
Mr Fall-Smith’s friend Rory Brewer said the pair took drugs recreationally – mainly cannabis, “benzos” (benzodiazepine), and opiates.
He said in the day or so before he died Mr Fall-Smith had been complaining about stomach pain and the pair “got loaded up” with drugs.
Another friend, Edward Dooley, said in a statement read out to the hearing the pair would “take anything we could get our hands on”, adding: “He was always looking forward to the next time when he was able to get high.”
When he discovered Mr Fall-Smith had died he said he was “completely shocked” and said he never thought their drug use would result in “one of us losing our life”.
Jane Sanders was, at the time, a support assistant at The Foyer, a 33-room residential unit which houses a number of clients who are there for independent living.
She told the hearing workers provided a level of support aimed to facilitate people’s independence rather than hands-on caring.
On March 16, 2016, she saw Mr Fall-Smith slumped on a windowsill at the entrance to the building before he later made his way to his room, saying he was okay.
When Ms Sanders carried out a handover with agency colleague Megan Marshall she suggested a check should be carried out on him.
Miss Marshall, whose role as support assistant was to organise activities for the residents, said she remembered Ms Sanders saying she was concerned about Mr Fall-Smith but couldn’t remember writing that there needed to be hourly checks due to his “concerning state”.
Paul Jennings, a support worker who has since died, said he had only discovered the reference to hourly checks after Mr Fall-Smith’s death.
Rhian Stone, managing director of Pobl Care and Support, said the company was not a registered care service, and was not set up for vulnerable adults. The staff tried to support people to engage with experts.
She said several changes had taken place since Noah’s death. These included the splitting up of accommodation to smaller units and a new method of recording resident information.
Delivering his conclusion Mr Bennett said at no stage was The Foyer registered as a care facility, adding: “The whole ethos of supported independent living is that each individual is meant to exercise responsibility for themselves.
“The problem with this is knowing where the boundary lies.”
Mr Bennett said an entry had been made into a logbook of a welfare nature but said: “Whatever the status of the entry the stark reality is that no-one did check on Noah in the hours that followed.”
He recorded the cause of death as morphine toxicity and gave a conclusion of drug-related death.
Speaking after the inquest Noah’s mother Karen Fall said: “We love Noah. He is irreplaceable. This should never have happened and should never happen again.
“We believed our beautiful Noah was in a safeguarded environment for young vulnerable adults. It took the death of Noah for Gwalia/Pobl to implement changes.
“His life and love was so significant to so many. This is evident for everyone at his favourite place – Noah’s ‘Pointless Tree’.”
The tree in Singleton Park was given its name by Mr Fall-Smith as he thought its spot in the middle of the park was “pointless”.
It has been used as a place of pilgrimage and contemplation for friends and family for the last three years.
His sister, Naomi Whitter-Jones, described the “huge hole that sits in our hearts and lives” after the inquest.
She added: “I am proud to say he was my brother and I will hold onto how lucky I was to have him in my life forever.”
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