On 3rd April 2014, opened an inquest into the death of: Lee Mark Anthony Bates, who died on 24th February 2014 at 01.18 hours; in Cambian Churchill London Clinic, It was concluded before a jury on 19th August 2015. The jury found that the medical cause of death was: 1a Zopiclone and Benzodiazepine usage and obstructive sleep apnoea II Severe obesity and concluded that the death was an accident

The jury found that: "At 0.18. Mr Bates died. The cessation of breath resulted in the CPAP machine stopping. His death was due to a potentially fatal overdose of Zopiclone being ingested in conjunction with benzodiazepines [Note: some were prescribed; some acquired] whilst under one t0 one eyesight observation. No evidence was heard to indicate that staff were sufficiently trained in the implementation of one to one eyesight observation policy: Contributory factors to his death were sleep apnoea and obesity. Technical evidence was admitted confirming that the Continuous Positive Airways Pressure (CPAP) machine delivered a prescribed pressure of air for sleep apnoea and was not a method of providing oxygen or a life support machine, but there was an event between 01.11 and 01.18_ An engineer's evidence was that the machine stopped at this time, but this did not necessarily indicate absence of iife as it could be due to one of three reasons: a) it was manually switched off There was no evidence this had occurred, The machine was managed by Mr Bates and not by the staff, but he was reported to have gone to bed with the mask on his face b) the mask has been removed The mask was witnessed to be on his face at 04.00 and 04.30 when the alarm was raised and CPR begun. c) there was a leak from mask e.g. from poor facial hygiene, beard or break in mask_ The CPAP mask and venting were inspected and were in good condition wth no blockage. strap was fine and fitted together properly_ Igave evidence that his small beard would be insufficient to cause the cessation of recording: The they '

It was reported to the court that hourly observation was noted at 02.00 and 03.00_ nurse gave evidence that she heard his breathing and saw his diaphragm going up and down between 03.00 and 04.00. She and a support worker turned the light on at 04.00 and saw that Mr Bates was moving indicating he was breathing: At 04.30 the support worker; observing from 14 feet away, instinctively felt something was wrong, noting he no longer heard the background noise of the CPAP machine_ The Cambian Churchill reported that since the death there had been a reissue of the observation policy, raised awareness of what it required and staff training: who heads the sleep apnoea clinic which Mr Bates attended in GSTT sald that his overnight oximetry showed he had falls in oxygen levels of 100 per hour; which were reduced to 2.5 per hour with the use of CPAP. He had therefore very severe sleep apnoea, which was dramatically controlled by use of CPAP ] said that there is cumulative damage if the CPAP machine was notused: night it would reduce, but not eliminate the risk of death_ He said that Lorazepam theoretically has an effect on breathing: It should not be used in untreated sleep apnoea_ If used when CPAP was on, it had the potential to make the sleep apnoea worse The impact is statistically small, but in more severe sleep apnoea is more likely to have an effect: He was at a loss to predict if its prescription had contributed to death: He said that the consultant neurologist who saw him in the sleep clinic did not know he was to be prescribed Haloperidol or Lorazepam. He gave no warning or information about risks of prescribing: The professor said that Lorazepam should be avoided, but did not criticize its prescription;, and would have expected the psychiatrists to contact the sleep clinic if thev needed advice. If Mr Bates had to have sedative drugs, and was in his hospital; Isaid that he would be monitored with an oximeter _