Procedures have been tightened up at Kent and Canterbury Hospital after a patient who absconded was found dead in the driveway of a nearby house just hours later.
Gas engineer Luke Leggatt suffered heart failure after taking cocaine but his treatment in hospital up to his death came under scrutiny at an inquest.
Now, as a result of his death, the policy of informing police that a patient has walked out of hospital has been extended to all patients and not just those considered a specific risk to themselves or others.
The inquest heard from nurses how the hospital was under extreme pressure due to staff shortages on the night Mr Leggatt was admitted.
He had been taken to the K&C by his worried brother, Steven, on December 16, 2016, after apparently suffering seizures and had to be helped from the car into A&E by medics.
Registrar Dr Viktoriya Clarke, who was just finishing her shift on the night, told the inquest that he "looked quite unwell" and she was made aware he may have taken something.
She said she did not get the impression he would leave but it might have helped if doctors had been given the whole story about the patient instead of "bits and pieces."
Hospital staff said Mr Leggatt, a 26-year-old dad, of Devon Road, Canterbury, was uncooperative and refused to have blood tests or be administered fluids.
Staff nurse Lucy George said: “He was left with health care assistant Ben Morgan to have basic observations including a blood test.
"Ben was trying to get blood but told me he wasn't allowing it. I went to explain to him why he had to stay and have the tests but he wasn’t listening to me and flatly refused. He was just saying ‘I want to go home’.
Nurse George said she was having to also attend to other seriously ill patients.
Mr Morgan said that Mr Leggatt was put on a heart monitor and his blood pressure checked. He said Mr Leggatt said he "felt ok, just a bit sweaty."
The inquest heard that medical staff wanted to set up cannula to give him fluids which would help flush his system through, but he refused.
Jacky Moskovits, who was a junior sister at the time, told coroner Ian Goldup that she had been made aware that Mr Leggatt was in resus having taken a recreational drug.
“I was too busy with other patients otherwise I would have gone to Luke to try and persuade him to stay and have the tests because I knew him as a child,” she said. “I will always regret that.
“But you can’t make someone have treatment if they don’t want it.”
A security guard was deployed to keep an eye on Mr Leggatt who was restless in the busy unit until a doctor could speak with him.
Mr Leggatt then told the guard he wanted to go to the toilet. But as he was being led to the facilities, he took a different turn down the corridor and walked out of the hospital.
His body was found the following morning in Abbots Barton Walk in Canterbury at about 7am.
Roger Swift spotted Mr Leggatt face down in a neighbour’s driveway and called police.
Officers investigated the circumstances and Det Sgt Stuart Ward told the inquest that there was no evidence of any foul play.
A post-mortem revealed Mr Leggatt had suffered heart failure after taking a fatal level of cocaine. Injuries to his face were consistent with him falling.
The circumstances of his death and how he was treated in hospital were subsequently investigated by the hospital.
Matron Gill Miller said the hospital’s missing persons policy was already under review but had how now been updated so that a safeguarding phone call is always made to police when a patient absconds.
The coroner heard that Mr Leggatt had a history of drinking and taking cocaine - a problem his GP, Dr Sioned Jones, said he had been determined to beat.
He had contact with a variety of substance abuse agencies and his family believed he had recently “been clean” for some weeks.
Coroner Ian Goldup recorded that Mr Leggatt’s death was drug-related.
Speaking after the inquest, his mother Patricia Mitchell said she was not seeking to blame the hospital for her son’s death.
“I appreciate that they were under extreme pressure and Luke wasn’t co-operative, but he was clearly in a confused state and I don’t think he got the care he should have ,” she said.
“He obviously wasn’t well because his blood pressure reading wasn't normal and they must have had concerns about him to get a security guard.
“It’s too late for Luke and us, but I just hope that the hospital’s updated policy will prevent another tragedy like ours in the future.
“Quite a negative picture has been painted of Luke because of his cocaine use but he was a lovely and intelligent young man.
“He suffered a nasty injury after being attacked some years ago in which his jaw was broken and said he never felt normal after that. He did have his problems, but I know he wanted to be so different.”