A teenager who died in a Pembrokeshire care home was happy and chatty in the days before his death, an inquest heard.
Luke Evans, 16, was found dead on June 9, 2021, in his room at Upper House Llandruidion ub Solva.
An inquest has heard that the day before he was "happy and chatty, looking forward to the future" talking to the home’s deputy manager about his job and things that he had posted on TikTok.
That evening he had gone to Whitesands beach with two other residents and members of staff.
He was described as "really good and in a good mood". Although he could be "a bit of a recluse", he wanted to go to the beach and had bought his new skateboard with him. He stayed in the car park with his skateboard and on the way back talked about skateboarding and his new job in the Bishops in St Davids.
The week before his death he had been on a trip to London and Harry Potter World with one of his key workers and arrived home excited and making plans for future trips.
At 8.30pm on June 8, he arrived back at the care home. He went to his room to play on his XBOX, he was allowed to go online and enjoyed playing Fortnite.
At 10.20pm he handed the XBOX in and went outside to smoke. He came back in at 10.38pm and handed in his phone and his lighter before going to bed.
Members of staff did not get the impression that he was unhappy or depressed.
The next morning a member of staff went to wake him at around 10.45am. He was not in his bed and was found in the corner of the room.
Despite attempts by staff and a local retired GP to save him, he was declared dead when paramedics arrived.
The inquest heard how Luke had been at the home in Solva for four years after his adopted parents found his behaviour increasingly difficult to manage.
However, he had made good progress during his time in the home, with staff members describing him as a mature young man.
The home’s manager, Sharon Mathias, described him empathetic, sociable, likeable and personable. He would take new arrivals under his wing and explain things to them. He was a charmer who liked to challenge the rules.
She added that he was the only resident of the home that she had ever allowed to take her beloved dog for a walk.
Luke had a history of self-harm. However, staff at the home said that this had not been evident in the months before his death.
His father, however, said that on their last meeting he had been shocked by the number of significant cuts on Luke’s arms but when he tried to discuss it, Luke changed the subject.
Luke’s father, said that Luke had "somehow got himself into a dark place", which was evidenced in an undated, one page written document found in Luke’s room after his death.
“He felt he wasn’t wanted, he wasn’t loved and everything was against him. I don’t know how he got there to be honest,” he told the hearing.
However, Mr Evans felt that Luke hadn’t intended to take his life.
“I still want to believe that he was doing something stupid and he took it to that point where there was no coming back,” he said.
“I don’t believe that he wanted to kill himself.”
Why do newspapers cover inquests and how do they work?
The inquest heard that Luke was enjoying college and had just had his second year place on his course confirmed. He hoped to become a graphic designer. He had just handed in a college assignment and had bought supplies for the next week in college.
He had a new job that he was enjoying and several circles of friends.
Mr Evans added that he felt that "Luke was given too much freedom at the home towards the end".
“He was given too much time on his own and was left unsighted for too long. I think that the fact that Luke said I’m fine. I’m okay’ and was just left on his own to do so much.
“If anything comes from this it should be that there are shorter gaps for keeping an eye on the children.”
Martin Davies, chief operating officer for Marlowe that runs the home, said that increasing observations on Luke "would not have been congruent" with the way that he was presenting and interacting.
“His death came as a shock to everyone and remains so to this day,” he told the hearing.
The inquest continues today.
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules here