Abdelslam Benelghazi inquest: Patient overdosed after psychiatric unit failures
A schizophrenic patient died from an overdose after failings by staff at a psychiatric unit, an inquest jury has concluded.
Abdelslam Benelghazi, 37, was in Juniper ward in Weston-super-Mare when he died in 2017.
He was given a combination of drugs that were known could lead to sudden death, the Flax Bourton court previously heard.
Avon and Wiltshire NHS Trust has apologised.
A narrative conclusion was unanimously reached by the inquest jury at Avon Coroner's Court.
It found staff failed to create a pharmacological care plan "to assess, monitor and review the patient and to communicate it to relevant staff".
A pathologist previously told the inquest a mix of methadone, painkillers and other medications could become toxic.
Another failure was the lack of intervention by medical staff, during the 48 hours preceding Mr Benelghazi's death, where it was noticed three times that the patient was presenting signs of sedation, the jury said.
Staff also failed to administer Naloxone, a drug which can block the effects of opiates like methadone in an emergency, the jury found.
Dr Sarah Constantine, medical director at Avon and Wiltshire Mental Health Partnership NHS Trust, said it was "deeply sorry" and the fully accepted the findings.
"We gave detailed evidence of the changes we have made to the ward and our practices and the coroner accepted these and did not feel any recommendations or warnings should be made against the trust, she said.
"We are sorry that this does not undo what happened to Abdi and the impact it has had on his family."