A foster-father has questioned why the child originally in his care was left alone for so long after he hanged himself in a home in Pembrokeshire.

Luke Evans was found dead on June 9 at Upper House in Solva.

The inquest into the 16-year-old’s death was opened last year, and on March 25 in a pre-inquest hearing at Llanelli Town Hall.

Luke’s foster father Martin Evans, along with Luke’s foster mother Anne Evans, described Luke’s chronic issues with getting to sleep.

Luke was put into foster care in Staffordshire, and after his foster parents struggled to care for him he was moved to a home in Solva.

Mr Evans described how he was ‘flabberghasted’ by the level of self-harm displayed on Luke’s arm, which he saw when he regularly visited Luke.

Mr Evans had seen Luke the Sunday before he killed himself, after Luke had been admitted to A&E for self-harm on more than one occasion.

Acting senior coroner for Pembrokeshire and Carmarthenshire, Paul Bennett said with Luke being in the care of social services he would consider whether Article 2 of the European Convention on Human Rights was engaged.

The article states governments should take appropriate measures to safeguard life.

Mr Bennett emphasised he was not pre-judging the case or making any findings at this stage.

Mr Evans said: “I think what happened should not have happened the way it did, and that is because I think he was left unsighted for too long.

“The sleeping was a major thing with Luke. I think they reduced his medication too quick. The self-harm on his arm was horrendous. I was flabbergasted with how much was on his arm it was that much. There are things that have happened that should not have happened in the way that they did.”

Representing Marlowe Child and Family Services Care Agency, which run the care home Luke died in, Martin Davies said the shock of Luke’s death was still affecting staff at the care home to this day.

Mr Davies said:

“The home was deeply affected by the events of Luke’s death and a number of staff have been receiving counselling and on-going support right up until now.”

Mr Bennett is set to hold another pre-inquest hearing before the inquest itself with no date as yet set.

The coroner mentioned that members of Solva GP and the child adolescent psychiatrist that treated Luke could be called.