Video1: Hello, I’ve just finished reporting on the inquest into the death of Peter Gary Seaby and I don’t have it in me to write a blog post so I thought I would record a quick video message to share some of what we’ve heard and some of what we’ve learnt in court.
The jury were sent out this morning with instructions from the Coroner that they could only consider a short form narrative, or a narrative conclusion, that were the only options available to them.
And they returned with a short form conclusion that Peter died from natural causes. To some extent that’s really probably all they could come back with. They could have written a narrative that was slightly longer but again it was very limited in what they could say.
Peter’s inquest was not an Article 2 inquest, um, so it wasn’t looking broadly at the context around his death it was just looking at who he was, when he died, where he died and how he died.
There were a number of interested person’s involved, his family, the care home which is run by the Priory Group, the general practitioner who saw him on the day before he died, um, and Norfolk County Council who commissioned his care and ultimately were responsible for it. And also the 111 service.
So, what do we know? We know that Peter lived happily, and mostly healthily in the care of his family for 63 years. We know that his family did not want him to go into care, begrudgingly agreed to a two week respite placement, which then turned into a five month placement. Peter had been in the care home, Oaks and Woodcroft, for coming up to six months when he died.
So he’d only been in the care of the state for six months and he died.
We know that he died from aspiration pneumonia. Secondary to that was Down’s Syndrome, cirrhosis of the liver and a cerebral infarction.
Video2: We know that Peter was on a soft, moist, fork mashed diet or should have been on one. Where his food should have been mashed with the back of a fork and if that weren’t possible it should have been pureed and there was a strict diet for what he could and couldn’t eat.
We know from the evidence we heard in court that was not followed 100%. We heard evidence that he was given crisps that he shouldn’t have been given. That he was given brown bread which he shouldn’t have had because of the nature of his swallow.
We heard of other foods, other meals where it wasn’t clear if the SALT plan, the Speech and Language Therapy Plan was followed.
We also know at post mortem a 2cm sliced piece of carrot was found in Peter’s throat. The court were shown pictures of this carrot in situ during the post mortem. But what we heard today, the Coroner told the jury they had to disregard the carrot because there was no expert evidence that the carrot caused or contributed to Peter’s death.
Peter died from aspiration pneumonia, which is what happens when food, drink or saliva enters the lungs. Commonly happens when food goes down the wrong way, if someone has poor posture, if somebody has dysphagia, difficulty swallowing, which Peter did. But because this piece of sliced carrot was found in his throat, and it could not be said beyond reasonable doubt* that it had caused or contributed to his death it had to be disregarded.
** This is an error, inquests need civil standard of proof, on the balance of probabilities, but my video editing skills aren’t good enough to change it **
The jury were also told that they had to disregard supervision as a factor in his death. We heard in court that the Council provided for 4 hours of 1-1 supervision for Peter every day to help with overseeing his eating and drinking. We heard that he should have had a ten minute break between eating and drinking, and that should have been supervised. He should have had 1-1 supervision for that and it was clear from the witnesses for the care home that didn’t happen, or on occasions it didn’t happen, and to be honest the witnesses didn’t seem to know that it should have been happening. Which is somewhat worrying.
But again because there was no expert evidence that [the video cuts off at this point but it should have continued] it directly contributed to his death, it had to be disregarded.
Video3: We also heard in court that in April, Peter died in May, but in April there was a choking incident in the home which required six backslaps for him as an emergency procedure to prevent him choking. He was seen by, they rang 111 afterwards and he was seen by the hospital and he was deemed fit, but they did not… it seems a bit confused, they did not report this routinely to the Council.
A social worker found out when they rang to say they were coming to visit Peter the next day and we heard from the Council representatives last week and it sounds like the incident report, which we didn’t see in court, but the legal parties had, it sounds like it did not accurately portray events that happened. I think the phrase it minimalised, it was minimised what happened.
So because the Council did not have this information, accurate information about how bad it had happened, they didn’t ask further questions and as a consequence no safeguarding investigation happened. Now, there’s nothing to say it would have happened, they might have asked more questions and then decided that they didn’t need to conduct a safeguarding investigation, but because the home didn’t accurately report it, there was no, there were no, there was no opportunity for that to happen. But the Coroner again ruled, because that was April and he didn’t die until May, that it wasn’t causative.
So, where are we at? We heard lots of evidence about things which from my perspective, as a member of the public, were incredibly concerning. We have care home records which seemingly aren’t accurate enough to be able to tell you whether Peter’s diet was followed. Lots of people who couldn’t remember. Differences between staff, some said the care plans were kept under lock and key in an office, others that they were in the kitchen. The record keeping was so poor, nobody knows who prepared the meals, or if they were prepared in keeping with his care plan, and if the 1-1 supervision was followed.
Video4: What we do know is that 63% of people with a learning disability will die before they’re 65, compared to just 15% of the general population.
We do know that aspiration pneumonia is the second most commonly cited cause of death on death certificates for learning disabled people.
We know that learning disabled people are three times as likely to die from an avoidable medical cause of death than the general population.
We know that 17% of adults with learning disabilities died from aspiration pneumonia in 2019, so that’s almost 1 in 5.
1 in 5 deaths of learning disabled people are as a direct result of aspiration pneumonia, and you have an increased risk of that if you are reliant on others for care, and for helping you with eating and drinking. Or if you have difficulty with eating, dysphagia, or difficulty with your swallow.
So I guess I don’t know what to tell you really. I don’t know what else to say. The jury were instructed to find natural causes or a narrative. They found natural causes.
The Priory Group who run the care home were adamant that things have improved now, this was three years ago, its not as it was then.
The Coroner clearly received submissions from the Council over the weekend and was suitably reassured that their auditing processes were more robust than perhaps witnesses had suggested last week.
So there is no Prevention of Future Deaths report to be issued. There is no follow up. This is it.
So yeh, I’ll update if I hear from Peter’s family but that’s where we’re at at the moment. Thank you.
Video5: I said I’d update if I heard from Peter’s family and I’ve got a statement from them so I thought I’d just update you with that. This is what their statement says:
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.
So that’s the statement from Mick and Karen Seaby, Peter’s brother and sister.
So that’s me done for today. Apologies there was no transcript on the videos. I am typing one up separately.
A quick thank you to all of my crowdfunders who have supported my reporting of Peter’s inquest, and all my inquests, and my contact with families in between them. I really appreciate it, and wouldn’t be able to do it without you. So thanks very much.
And as ever all your thoughts are very welcome. Please keep the conversation going. Thank you.