An inquest into the death of a 27-year-old man with complex needs, including epilepsy, found he died as a result of near drowning, insufficient supervision and inadequate medical care.

At the time of his death, in March 2015, Greg Roult was on holiday at the Sonesta Beach Resort in Sharm el Sheikh, Egypt with two of his carers, who were employed by Lancashire County Council.

Greg was in the swimming pool with both carers when he suffered a seizure, and was found lying at the bottom of the pool.

Despite attempts to save his life, largely by one of his carers and other holidaymakers, he sadly died later that day in hospital.

It has taken six years for the inquest into Greg’s death to take place and despite repeated efforts to obtain information from Egypt, the hotel, hotel doctor and hospital failed to co-operate.

At the three-day inquest in County Hall, Preston, a jury heard evidence from a number of witnesses, including the two carers, senior managers at Lancashire County Council, the hotel representative, and holidaymakers that made efforts to save Greg's life.

It was heard that due to Greg’s complex needs resulting from his cerebral palsy and epilepsy, he required constant supervision, and the bungalow where Greg lived with his carers required decorating, so a holiday for Greg during this time was agreed to avoid disruption.

The holiday guidelines were completed by carers, and included a swimming risk assessment, however, the risk assessment was not tailored to the trip to Egypt and the associated risks.

Whilst Greg’s carers conducted an onsite risk assessment relating to depth of the pool, proximity of room and availability of refreshments, the pool did not have a lifeguard and was a considerable distance to the doctor’s clinic.

On March 26 2015 after returning from a boat trip, Greg’s carers decided that it would be beneficial to take him to the pool to help with transitioning to the evening activities.

The inquest heard that after a duration of time in the water, visual contact from the carers was lost with Greg and he was found under the water unconscious.

Following Greg’s removal from the water he became conscious but deteriorated after a period of time, as the onsite doctor’s intervention and equipment were deemed not fit for purpose, which resulted in a carer and tourist taking over the CPR.

Following this, the medical provision provided by the Egyptian healthcare was found to be inadequate, due to no CPR being performed on Greg by the ambulance workers who showed a lack of urgency in treating Greg.

The inquest also found that the hospital staff had been misleading on the amount of time and level of care that Greg received, which on the balance of probability was also found to be inadequate.

Lancashire County Council's executive director for adult services, health and wellbeing, Louise Taylor, said: "This was a tragic loss of life in a very difficult set of circumstances.

"We understand it must be so difficult for Greg's family reliving details of what happened.

"Our thoughts and sympathies remain with them, as well as his friends and all those who knew and cared for him and we're sorry for their pain and loss.

"Holidays are things people should look forward to. We will continue to do all we can to protect people who use our care service and respect their wishes to live a full and active life safely.

"We have conducted a full review following this incident."

Area Coroner James Newman said he intends to send a prevention of future deaths report to the Foreign Commonwealth Office and the Association of British Travel Agents setting out his grave concerns about the hotel doctor’s ability and qualifications, the medical equipment at the hotel and the lack of medical treatment carried out by paramedics and hospital doctors.

The report will be forwarded to the Sonesta Beach Resort and the Sharm International Hospital.

Mr Roult's parents were represented throughout the proceedings by specialist inquest solicitor Kelly Darlington and her team at Farleys.