A patient who lay dead in a hospital toilet for two days before his body was found had not been reported missing for more than four hours after leaving his ward to have a cigarette, an inquest heard on Wednesday.

The manager of the Gloucestershire Royal Hospital ward where Jonathon Earp, 32, was being treated told an inquest he was surprised that the alarm was not raised sooner.

He would have expected staff to go looking for him if he had not returned to the ward within 30-45 minutes, he said.

Jonathon Earp

The Gloucester inquest heard that Mr Earp, who was being treated for a suspected blood clot in the leg, had already been found collapsed twice in the same disabled toilet in the two days leading up to his death.

He was suspected of locking himself into the toilet to use illicit drugs.

Then on July 7 last year at 10.55pm Mr Earp, who had been complaining he was not getting enough pain killers, told a nurse he was going outside the hospital building for a cigarette.

GRH Tower

The alarm was not raised till 3am - but it was another two days before his body was finally found in the ground floor toilet on the morning of July 10.

Detective Sgt Tristran Jones stated that Mr Earp, of Westend Terrace, Gloucester, was found lying face down on the toilet floor.

"I was told he had been removed from the same toilet cubicle on two separate earlier occasions during the course of his treatment after collapsing on the floor," said the sargeant.

"Staff said they believed he had been consuming crack cocaine in the cubicle."

Pathologist Dr John McCarthy said Mr Earp was a drug addict who had been treated with numerous medications and had suffered deep vein thromboses and pulmonary embolisms in the past.

He found many drugs present in the body - including morphine, diazepam, Zopiclone, alcohol and cocaine, he said.

The doctor gave cause of death as the combined toxic effects of all the drugs.

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Dr McCarthy estimated that Mr Earp had been dead for at least 36 hours before his body was found.

The scene outside Gloucestershire Royal Hospital after the body was found
The scene outside Gloucestershire Royal Hospital this morning

A statement from one of the doctors on Ward 4A where Mr Earp was a patient said he had needed strong pain killing treatment since 2000 when he injured his back in a road accident. The injury had troubled him all his life.

He had suffered two previous blood clots in the legs and one in the lungs in the past.

Mr Earp had been admitted to Gloucestershire Royal Hospital on July 5 and had 'compliance issues' because he was asking for extra painkillers even though he was on a high dose already, the report said.

The statement also said Mr Earp had been 'living dangerously for some time' because of his high doses of medication and possible illegal drug use.

"The likely cause of this tragic event is using additional illegal drugs on top of prescribed medication which might have tipped him over to toxic levels," the statement said.

Gloucestershire Royal Hospital

The Ward 4A manager at the time, Matthew Little, said Mr Earp had a collapse in the toilet on July 6 and again on the morning of July 7 and was found both times and returned to his ward.

"He found it very stressful on the ward and he was regularly going out to clear his head, to have a cigarette," he said.

"On July 7 he left the ward at 10.55pm. He was noted to be agitated before leaving the ward. He said he was being lied to and he didn't know why he was in hospital. He said he needed a cigarette to calm him down.

"I would expect staff to keep an eye on the time for 45 minutes and to check if he is not back."

The coroner pointed out it was 3am before the alarm was raised and asked Mr Little to comment on that.

He said: "I would expect staff to go and have a look. Go down to the front desk and see if he is out there having a cigarette. "

Asked if that had happened he said there was no documentation to say so.

He went on: "He was being looked after by an agency nurse on that shift."

Mr Little agreed with the coroner that an inquiry carried out by the hospital trust found that the nurse on duty was not aware of Mr Earp's two previous collapses in the toilet.

He would have expected that to be discussed at the nursing shift handovers, he said, and he was surprised it had not been.

He also agreed that records made by the nurses were not as full as they should be .

"There is not as much information as I would have liked to be in there," he said. Asked by the coroner what the reason for that might be he said it might just have been 'hevay workload.'

Dr Amer Farooq, who was working on the ward at the time, said Mr Earp had complained to him that he was not getting adequate pain killers. Mr Earp had also been saying he would discharge himself and that he had a family funeral to go to.

The doctor said he warned him he would be at risk of a fatal blood clot if he discharged himself and did not have blood thinning medication. He advised him that if he discharged himself he could still return to the ward or to a warfarin clinic for treatment.

The inquest is continuing.