Failures could have “caused or contributed” to the death of a student who choked on his own vomit at Bodmin Hospital.
That was the conclusion of the jury at an inquest into the death of 28-year-old Pawel Bielec, from St Ives.
The four-day hearing was told that Pawel had been allowed unsupervised leave from Fettle House psychiatric rehabilitation unit at Bodmin Hospital on July 1, 2016
He had returned drunk and was later found unresponsive after choking on his vomit. He died despite efforts to resuscitate him.
Pawel, who was diagnosed with Asperger’s syndrome and also suffered from psychosis and anxiety, was sectioned and detained at Fettle House.
Nursing and healthcare staff decided to instigate Level 2 observations on Pawel every 15 minutes rather than Level 3, which would mean a member of staff alongside him at all times. They agreed that their continuous presence would rile him and make him unsettled.
He fell asleep at 5.30pm and healthcare assistant Richard Bolt ensured his airway was clear and he was in the recovery position. At 7.15pm Pawel was found to have choked on his vomit. He died despite attempts to resuscitate him.