Coroner highlights missed opportunities in care given to 22-year-old William Giles before his death

The inquest into the death of 22-year-old William Giles, who died in hospital on 23 August 2023 has found that there were missed opportunities in the care he received at hospital in the period leading up to his death. 

William – known as Will – from Oldbury in the West Midlands, died after taking non-prescribed medication on Clent Ward, at Bushey Fields Hospital in Dudley while receiving in-patient treatment for his mental health.

At the conclusions hearing, HM Assistant Coroner Kelly Dixon, said there was “no structured approach” for the risk management of substance misuse and that opportunities for staff to detect contraband were missed. Ms Dixon also said that the failure to complete observations from 5am onwards on 23 August 2023 was an omission in Will’s care and that it was not acceptable for staff to record that Will “appears asleep” when they had been unable to establish whether he was breathing. 

The coroner also found that: 

• Will did not receive the standard of care expected and there were multiple instances during the early hours of the morning on which he died, where observations fell short
• The absence of a substance misuse care plan, which was essential to manage Will’s risk and his care, constitutes a failing in Will’s care
• There was a lack of specialist support for drug and alcohol misuse on the ward.
• There was a failure to complete searches of Will when he was returning from leave, despite the escalating risks. 

• There was a failure to implement risk management measures for Will’s care, and it was noted he was a patient with vulnerabilities and issues with self harm

The coroner ultimately found that there was not enough evidence to conclude that these missed opportunities contributed to Will’s death. She is now considering whether to issue a prevention of future deaths report. 

A three-day hearing at Black Country Coroner’s Court starting on 24 November 2025 examined the care and treatment provided to Will during his admission, including the adequacy of overnight observations, whether appropriate monitoring and management plans were in place for substance misuse, and the use of illicit substances on the ward.  

The court heard evidence from those involved in Will’s care at Bushey Fields, and in the community, and from an independent expert in acute internal medicine. 

The court also heard evidence from William’s mother, Lisa Venables who told the court how Will had struggled with his mental health from an early age and how he was diagnosed with depression at 12 years old. 

Throughout his teenage years and into his 20s, Will continued to struggle with his mental health and was in and out of hospital and had tried a number of different therapies.  

Lisa also told the court that a number of events throughout Will’s life – including losing his father to suicide – contributed to his mental health struggles. 

The court was told that Will became withdrawn, anxious and depressed, and was disassociating, and at the end of July 2023, had started to self-harm more often. He sought professional help as he was feeling suicidal and very low. The court was told that Will and his mother were informed that a bed had become available at Bushey Fields Hospital in Dudley.  

Lisa told the court that on a number of occasions she and Craig, Will’s stepfather, had brought items from home for Will. She said that in other hospitals her bags were checked for security purposes but that at Bushey Fields her bags were never checked unless she asked for them to be. Lisa said that this concerned her and what this meant for the safety and security of the ward Will was on as she could not see anything to suggest that any patients were searched when re-entering the ward following leave. 

Will’s mother Lisa is represented by Elizabeth Cleaver, instructed by Jess Smith of Leigh Day.

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