Coroner highlights missed opportunities in care given to  22-year-old William Giles before 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 solicitor Jess Smith from law firm Leigh Day and barrister Elizabeth Cleaver from Doughty Street Chambers.  

Lisa Venables, William’s mother, said:  

 "No family should ever have to go through what we have. Will was a kind, loving son and caring brother who desperately wanted help. He went into hospital to be kept safe, and we trusted that he would be cared for.   

“I believe mistakes were being made in the way Will was treated and that the missed opportunities identified by the coroner could and should have been identified sooner.”  

 “Whilst nothing can ever bring Will back, I urge the NHS trust responsible for caring for him to learn from what happened so that no other family has to experience the pain we have endured.”   

Jess Smith said:  

"The evidence heard at this inquest has revealed deeply concerning missed opportunities in the care provided to Will at Bushey Fields Hospital. Despite clear risks and repeated warnings, safeguards that should have protected him were not in place.  

"Without this inquest, this would never have come to light. Lessons must now be learned to prevent further cases like Will’s and to ensure that no family has to go through such pain.”