A former care worker at the Pembrokeshire care home where a teenage boy took his life has told an inquest that she cannot understand why greater safeguarding measures were not put in place.

Sophie Ann Pow, a qualified paediatric nurse, was not due to give evidence at the inquest into the death of Luke Evans. However, after hearing evidence this week she felt compelled to make a statement.

Mrs Pow worked at Upper House Llandruidion, Solva, where 16-year-old Luke Evans took his life, between October 2019 and March 2020, finishing because of health reasons.

She told the inquest that new therapeutic care workers had two week’s initial training before starting their probationary period. After the initial training she told the inquest that trainee care workers had a few weeks in the home reading the children’s case histories.

However, after this period they were allowed to be unsupervised with what she was told were some of the most vulnerable young people in the country.

Mrs Pow said that during her short time at the care home she had found heavily blooded towels twice and a blade hidden in Luke’s room.

She said that she reported this to senior staff but was not asked to make a report, being told that senior staff would do that.

Why do newspapers cover inquests and how do they work

Death of likable teen in Pembrokeshire care home was 'huge shock'

Inquest begins into death of 'beautiful caring, funny' teen in Pembrokeshire care home

“Given my background that did not sit well with the All Wales Safeguarding Policy,” she said.

She said that there was no evidence that Luke’s care plan was altered after these events and no changes to his room and said he should have been referred to the child and adolescent mental health service CAMS.

She also questioned why cables were left in Luke’s room overnight at the time of his death. Saying that when she had been at the home cables had been removed from the boys’ rooms at night, she was told this was part of their care plan for sleep hygiene.

She said that she could not understand why, after a self-harming episode in November 2020 when she had seen Luke in A&E, further steps had not been taken to remove items of possible danger from his room.

She added that Luke had screws in the wall of his room [to display hats and hoodies]. But that in her opinion, to remove the risk of sharp objects, these should have been replaced with stick-on plastic hooks.

“Safeguarding has to come first,” she said.

Under questioning she admitted that she did not know the severity of the self-harming in the incidents referred to, as she had been told that senior staff would follow it up. By the time of the November 2020 incident she was no longer working at the home.

In evidence given to the coroner on Wednesday, Martin Davies, Chief operating officer of the care home said that staff training was an ongoing statutory process under which probationary staff had to obtain a level three qualification.

He added that other targeted training was also provided.

Mr Davies pointed out that that a copy of Luke’s care plan had been provided to the coroner’s office, which for some reason had not been included in the bundle.  In this care plan there was evidence that, on occasion, care had been altered, for example waking night shifts where Luke would be checked every 15 minutes, following self-harm incidents.

He said that cables had been removed from rooms for sleep hygiene and there was no self harm ligature risk presented with Luke.

Coroner, Mr Bennet, asked why a self-harm risk assessment had not been updated following a significant incident in November 2020. Mr Davies said that this was possibly because the mitigation measures remained the same.

He drew attention to Luke’s input into his final looked after children meeting in which he said that was looking forward to his second year of college, was saving for driving lessons from his part time job and was working towards a plan for university and working towards keeping his phone and charger in his room overnight.

He said that the way that Luke presented at the time before his death did not justify increased mitigation measures.

“This is what Luke was working towards and what Luke wanted and these things are completely incongruous with taking your own life,” he said.

Evidence, from Owen Dorkins, from Staffordshire County Council, who chaired Luke’s review meetings, backed this up.

He said that in the final meeting held in January 2021 things seemed positive for Luke.

He had gained good grades in his GCSE course at Pembrokeshire College and was going on to study graphic design as well as looking at the possibility of going to university.

He said he loved being at upper house and had made a life for himself in Pembrokeshire. He had expressed the wish to remain in the county and the first steps had been taken to explore supported post 18 provision for him in Pembrokeshire.

“It came as a shock when I received the news that he had ended his life,” he said. “He never gave any indication that he was contemplating ending his life.

The final evidence will be given in the inquest on Wednesday, October 23, with the coroner’s conclusion expected by the end of this week.