A teenager who ended his life at a Pembrokeshire children’s home did not realise the fatal consequences his actions would have, Pembrokeshire coroner concluded today.

Luke Evans, 16, was found dead in his room at Upper House Llandruidion, Solva, on June 9, 2021.

A post-mortem carried out by Dr John Murphy, returned a conclusion of hanging. Toxicology reports showed that there were no drugs or alcohol in Luke’s system at the time his life ended.

After three days of evidence from witnesses including Luke’s adopted parents, the care home staff and management, Staffordshire Social Services and an expert in child health and medicine, Pembrokeshire Coroner Paul Bennett reached his conclusion today, Thursday October 24.

The inquest had heard about an incident in November 2020 when Luke, who did habitually self-harm, had cut himself deeply and had to be taken to A&E.

The hearing was told that this incident had scared Luke. He had not meant to cut himself so deeply and had done so because he was under the influence and had used a different implement.

Mr Bennett said that, after considering the evidence, he felt that the events of June 8 into June 9 were of a similar nature; that Luke had acted impulsively without realising the possible consequences of his actions.

He said that Luke had characteristics of undiagnosed and untreated ADHD, including impulsive behaviour.

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He did however say that a self-harm risk assessment held by the children’s home should have been updated to include that incident.

Mr Bennet added that he did not feel that removing cables from Luke’s room should have been part of his risk mitigation, as he had never harmed himself with ligatures, only with sharp objects.

A one-page written document which ‘seems to be written about whether he should live’ was found in Luke’s room after his death.

However, the coroner said that this was ambiguous and did not convey a ‘settled intent to end life’. As the document was not dated the coroner said that it could not be confirmed if it was contemporaneous with the events of June 2021.

Mr Bennet said that there was no evidence of suicidal ideation and that there was a distinction between self-harming and suicidality.

He added that in Luke’s final looked after children (LAC) review [in January 2021] he was ‘planning for the future rather than to end his life’ and that he had ‘expressed many positive goals’.

“This was an act of impulsiveness, possibly a cry for attention. There is enough evidence to suggest that this was a deliberate but impulsive act, characteristic of someone who suffers from ADHD,” said Mr Bennett.

“I am satisfied on the balance of probabilities that while this was a deliberate act it was not expected to lead to death.”

Mr Bennett recorded a conclusion of misadventure, saying: “Luke died from asphyxia. He died as a result of deliberate [actions] where he was unable to appreciate the fatal consequences of doing so.”

Mr Bennett extended his condolences to Luke’s family and thanked the witnesses for their cooperation in the inquest.