The death of a 66-year-old patient at Llanarth Court Hospital was deemed accidental after he choked on a pasty, an inquest heard.

On December 27, 2012, while returning from Nevill Hall Hospital, Brian Haydn Evans was given a pasty by a fellow patient, which he them forced into his mouth before any of the staff had a chance to react.

Staff performed the heimlich manoeuvre to try and dislodge the pasty, and an ambulance was called, but Mr Evans could not breath unaided and died at Nevill Hall Hospital two days later

Mr Evans, who was detained at the hospital under the mental health act for chronic schizophrenia, had developed regular chest problems over 2012, but refused to be treated for this.

On the day of the incident, Mr Evans had been let out of hospital after being admitted for breathing problems, and had returned to the facility where Health Care Worker, Mr Daniel Harris, was taking him to the intensive care unit.

Upon passing the dining hall, Mr Evans was handed the pasty by another patient at Llanarth Court, and thrust it whole into his mouth.

The post-mortem of Mr Evans concluded that his death was the result of hypoxic brain damage and pneumonia, due to his airways being obstructed for a length of time.

Gwent Coroner, David Bowen said how it was 'impossible to predict sudden and impulsive actions' of a person, and that there was no evidence to suggest his death was a result of lack of care.

He also stated how it was not evident that Mr Evans, who had not been on solid food for some time, did this with the intent of choking, and after a short deliberation the jury returned a verdict of accidental death.

An open verdict was returned at the order of the coroner last week, during an inquest into the death of a Llanarth Court Hospital patient.

Mr Kevin Ryan, 58, who was admitted to Llanarth Court for schizoaffective disorder, was found on the floor of his room with his head on the bed, by cleaner, Mr Jeff Jackson on April 22, 2013.

Mr Ryan, who was previously diagnosed with bipolar affective in 1997, was placed on enhanced observations, having to be checked on every 15 minutes due to his changes in mood and behaviour.

The jury heard that Mr Ryan would fluctuate from being completely dependant on staff, to being very independent, and would have Parkinsonian-type side effects from his medication.

But despite his physical health being deemed good, he refused to have any brain scans, and would regularly fall or put himself on the floor.

After Mr Ryan was discovered by Mr Jackson, Health Care Worker Daniel Harris was called, who checked his breathing moved him from the bed to the recovery position, as more staff arrived.

His breathing was shallow, and they attempted to use defibrillators and oxygen to assist this, but Mr Ryan died later that day.

The court also heard his post-mortem, undertaken by pathologist Dr Richard Jones on April 24, returned only two things of note.

One was a small abrasion mark on his neck with no underneath bruising which, due to the evidence given in court of the position in which Mr Ryan was discovered, was unexplained.

The second was that his brain stem had a degenerative process which was symptomatic of Parkinson's disease, but not usually found from medication related Parkinsonian symptoms.

Due to lack of any solid conclusion from the pathologist, no verdict on how the death occurred could be reached.

Gwent Coroner, David Bowen said, "The point of an inquest is to look at who died, where, when and how. It is not our job to speculate, and in this case, the evidence is not sufficient to come to a conclusion as to how Mr Ryan died."

Mr Bowen then ordered the jury to return an open verdict, and apologised to the family of Mr Ryan, saying that he was aware this conclusion was not what they wanted from the inquest.