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A teenager found hanged in the bedroom of his children's home did not intend to end his life, a coroner has ruled.

Luke Evans, 16, died at the home in Solva, Pembrokeshire, on 9 June 2021, after what Acting Senior Coroner Paul Bennett described as an "act of impulsivity".

The Pembrokeshire inquest heard Luke was "unable to appreciate the fatal consequences" of what he had done and that his impulsive actions had been "consistent with someone suffering ADHD".

Mr Bennett concluded that Luke "had committed a deliberate act" but "not intend to end his life" and ruled the death was the result of misadventure.

Mr Bennett said that, although a document found in Luke’s room - written by him - discussed whether to live or die, the content was "ambiguous" and had "no settled intent to end his life".

The four-day-inquest heard that there had been at least two serious incidents of self-harm involving Luke during his time at the home.

His adoptive father, Martin Evans, told the inquest he felt Luke had “too much freedom” in the home towards the end of his life and spent “too much time on his own.”

"No child in care should be left unsighted for that length of time."

Luke, originally from Staffordshire, had been a resident at the home in Pembrokeshire since 2017.

He had been adopted by Mr Evans and wife Anne, along with his sister, when he was an infant, but the couple could not cope with his behavioural problems and asked Staffordshire Social Services for help, who placed Luke in care.

After the inquest Mr Evans gave his reaction saying that he and his wife thought the misadventure ruling was the "right conclusion".

“He was a rogue, but he was our rogue," he said.

"He’d infuriate you one second and then do something that would charm you to death the next second. That was Luke. He was loveable."

Martin Davies, boss of Upper House Solva, where Luke died, said: "I would firstly like to again extend my condolences and best wishes to Mr and Mrs Evans.

"Luke was much loved by all at Upper House and his tragic passing continues to have a profound and lasting impact."

"We are grateful for the time and careful considerations of the coroner which enabled him to arrive at his conclusion of death by misadventure.

"We feel this outcome appropriate and hope it brings a crumb of comfort to all involved, who were so shocked at Luke’s passing."

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