The death of a man in a Staffordshire mental hospital may have been caused by missing his vital medication, an inquest heard.
But medical experts said that if 26-year-old Simon Scott had his epilepsy medication on time, it may not have saved him anyway.
Mr Scott, from Pittshill, Tunstall, was found dead at John Munroe Hospital in Leek in October 2014.
A Hanley Town Hall inquest heard Mr Scott had been an insulin dependent diabetic from the age of eight.
He had also been treated for epilepsy after a history of seizures.
The inquest heard how staff were supposed to check on him every 15 minutes after he went to bed on October 9 2014.
Mental health nurse John Gutkowski took the clinical decision not to administer Mr Scott’s epilepsy medicine at 10pm as he was sleeping.
He was checked at 10.30pm and then 10.50pm, when he appeared to be breathing and was asleep.
But at 11.05pm, Mr Scott was found unresponsive by a member of staff.
Dr Ben Akande, medical director at the hospital, said: “The nurses have to use their judgement of when to give medication.
“Because of Simon’s sometimes aggressive behaviour, Mr Gutkowski made the decision to leave him sleeping and return later to administer his medicine.
“It is unlikely that if he had the medication at that time, it would have changed the outcome.”
Dr Simon Ellis, a consultant neurologist who specialises in epilepsy, said: “I think the outcome for Simon would have been the same even if his medication was taken at 10pm.
“Unfortunately, he was a candidate for sudden death in epilepsy.”
Staff at the hospital carried out CPR until the paramedics arrived.
Paramedic Philip Hunt, from the West Midlands Ambulance Service, responded to the call at the hospital on Biddulph Road.
He said: “When I arrived I took over CPR from the staff for over 20 minutes until we decided nothing more could be done.
“I would like to say the staff performed CPR to a high standard and I could not have asked for anymore in the attempt to save the patient’s life.”
Pathologist Dr Olefin Biedrzycki told the inquest: “It is very difficult to say if Simon’s death was caused by Dead in Bed (DIB) syndrome, sudden death in epilepsy syndrome or both.”
DIB syndrome is used to describe the unexplained death of someone with type 1 diabetes.
It usually occurs when someone with an insulin dependent diabetes goes to bed seemingly fine and is then found dead.
SUDEP is the sudden, unexpected death of someone with epilepsy who was otherwise healthy.
Mr Scott’s mother, Alison Hemmings, said: “I was sleeping in bed when I had a phone call from the hospital saying that Simon had passed away.
“I was devastated and couldn’t believe what I was hearing as he seemed fine when I spoke to him earlier.”
The inquest earlier heard how Mr Scott had suffered a serious assault at his home on Francis Street, Pittshill, in November 2010, which left him brain damaged, with a fractured eye socket and several puncture wounds.
But Det Con Kevin Boyles, from Staffordshire Police, told the court there was no link between his death and the attack, for which two men were later convicted and jailed.
The jury returned a verdict that Mr Scott died of sudden unexpected death in type 1 diabetes and epilepsy.
The jury also said the hospital’s observation regime may have contributed to his death.
Margaret Jones, Senior Assistant Coroner, said: “To the family, I am extremely sorry for your devastating loss.”
(Additional reporting by Gemma Walsh)
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