The inquest into the death of Ruairi Stewart concluded on 20 February 2026, with the jury determining that his death was drug‑related.

During the hearing, the jury found that throughout Ruairi’s time at Weaver Lodge, a residential hospital operated by Alternative Futures Group (AFG), there were repeated failures to follow required policies and procedures. These failures included errors and omissions in:

  • Shift handover documents
  • Section 17 care plans
  • Section 17 leave of absence paperwork
  • One‑to‑one documentation
  • Clinical review/professionals’ meeting records

Follow‑up actions were not completed, and there was no evidence of internal auditing to ensure compliance with policies and procedures.

Communication between nurses, management, and clinicians was also found to be inadequate, resulting in clinical decisions being made using inaccurate or outdated information.

The inquest was heard over five days at Cheshire Coroners Court, before HM Assistant Coroner Elizabeth Wheeler.

Background

Ruairi Stewart had a long history of mental ill health and substance misuse, including previous periods of detention under the Mental Health Act.

On 18 August 2022, he was detained under the Mental Health Act.  On 7 January 2025, having shown some improvement and stability, he transferred to Weaver Lodge Independent Hospital in Winsford.

Throughout his time at Weaver Lodge, Ruairi was granted Section 17 leave, which allows detained patients temporary leave from hospital. Leave may be escorted or unescorted, short‑term or long‑term, and is granted by the Responsible Clinician.

Section 17 leave was revoked on several occasions after Ruairi provided positive drug tests. Some of these positive tests occurred during periods when he had not left the ward, suggesting he had accessed drugs within the unit.

The final reinstatement of Section 17 leave occurred on 29 July 2025.

On 30 July 2025, Ruairi had a period of escorted leave with a staff member, followed later by unescorted leave. The staff member who authorised the unescorted leave was aware of recent drug relapses but not aware of a recent conversation in which Ruairi had expressed an intention to continue using drugs, despite acknowledging the risks.

Ruairi was last seen alive in the early hours of 31 July 2025.

Between 07:30 and 08:00, he was found deceased in his room.

Concerns of the Coroner

HM Assistant Coroner Wheeler issued a Prevention of Future Deaths (PFD) report to Alternative Futures Group, raising multiple concerns, including:

  • The named nurse’s shift pattern meant she could not attend MDT meetings, leaving her input limited to written notes, which were often inaccurate or not reflected in the records.

  • Poor information sharing—both written and verbal—meant that risks relating to unescorted leave were not fully considered.

  • Care plans that should have been in place were either not created or not fully completed.

The coroner noted that similar concerns about the quality of AFG’s internal investigations had been raised previously in a Regulation 28 report issued by the Manchester City Coroner in 2022, relating to a death in 2018.

Addressing Ruairi’s family at the conclusion of the inquest, the coroner said it was clear that he was a much‑loved son, and that those who knew him described him as a fun and vivacious soul.

Ruairi’s family commented:

“Of the many tragedies surrounding Ruairi’s death, one of the greatest is that both he and we genuinely believed he was finally reaching the light at the end of the tunnel. After spending two and a half years at Bowmere Hospital in Chester, he had moved to Weaver Lodge Independent Hospital and, through his own determination and progress, had secured a self‑contained flat within the unit. He was able to cook for himself and welcome us for visits — something that meant so much to him.

“Ruairi had started to lose weight, was trying to get fit again, and was feeling hopeful about the future. We all shared that hope with him.

“We are grateful that the coroner has recognised the many concerns about AFG’s conduct that became clear during the hearing. Our only wish now is that meaningful changes are made so that no other family has to endure what we have been through.”

Ruairi’s family were represented by Farleys Associate, Natalie Tolley, and Barrister, Rebecca Titus‑Cobb of St John’s Buildings Chambers.