On Monday 23 August 2021 the jury in the inquest touching on the death of Peter Seaby retired. The Coroner had summed the evidence up for them and concluded that the only legally safe and just conclusions that they could reach would be a short form conclusion of natural causes, or a short factual narrative.
The jury found that Peter died from natural causes.
This is the statement that his brother Mick, and sister Karen, issued on the conclusion of the inquest:
Peter had Downs Syndrome, but that didn’t make him any less of a person. He was described in Court, and his family know, just what a cheeky, loveable chap he was. He was entitled to dignity and care like any of us. The whole purpose of that care home, which took him away from the care of his family, was to look after him safely.
The family still need answers about why his Speech and Language Therapy care plan was not fully adhered to. Why the care home did not alert social services properly after Peter choked and had to have his back slapped six times to have his life saved, one month before his death. And why, now that social services know this is what happened, they are still not saying they would absolutely investigate a case like the April 2018 choking incident. We need to see changes in the system.
We will never forget our brother. It is because of him that we want to make sure something like this never happens to any other vulnerable person in our community again. Peter was not the first person with learning disabilities to die in a care home in Norfolk, but after today, we hope he will have been the last.
We strongly believe had Peter continued to live at home with, and be cared for by, his family, he would still be with us today.