Questions have been raised as to why a 16-year-old who died at a Solva children’s home had his sleep medication reduced without seeing a specialist in person.

At a pre-inquest review into the death of Luke Evans Pembrokeshire Coroner, Paul Bennett heard that the teenager’s medication was gradually being reduced. This was being overseen by a specialist, but it was understood that Luke hadn’t been seen in person.

Luke’s foster father, Martin Evans, said that he and his wife Anne had had to ‘jump through hoops’ to get Luke the medication when he lived with them in Staffordshire.

He added that it ‘wasn’t right’ that the same medication was reduced without Luke physically seeing a specialist.

“They didn’t actually see him,” said Mr Evans. “They altered the dose without seeing him face to face. That’s not right.

“We had to jump through hoops up here and see a specialist. Luke had to be put in front of a person. If they haven’t seen him, and done it over the phone that needs to be seriously looked at.”

Martin Davies from Marlowe Child and Family Services Care Agency, which runs the Solva children’s home, said that Luke’s medication was being reduced in small doses over a period of many months and his sleep patterns monitored.

He said that the reduction had had not had an impact on Luke’s sleep pattern.

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Mr Evans questioned whether Luke’s sleep patterns were being properly monitored.

“We know that he was left unattended for 12 hours. That’s not monitoring his sleep pattern,” he said.

At a previous hearing Mr Evans had again flagged up the reduction in Luke’s medication and problems with sleeping, as well as evidence of self-harm.

The hearing heard that Luke had previously lived in Staffordshire but had moved to Solva in 2017 after his foster parents ‘reached a crisis being able to manage him at home’.

He died at Upper House, Solva on June 9, 2021.

Pembrokeshire Coroner, Paul Bennett set the scope of the inquest, the timeframe it would cover and the interested persons during Thursday’s hearing.

No date has yet been set for the final inquest.

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For help with mental health issues contact: mind.org.uk; samaritans.org and for young people papyrus-uk.org.