Peter Seaby’s 2nd inquest – record keeping and decision making

There were so many issues that emerged during the court of Peter’s second inquest. I can’t blog about all of them, but I wanted to just focus on record keeping and decision making at Oaks & Woodcroft, before the final post which will focus on the Prevention of Future Deaths evidence given by the Director […]

Peter Seaby’s 2nd inquest – May 2018

I’ve written a number of posts reporting Peter’s second inquest now, a quick recap incase this is the first one you’re coming to. There’s one about how he came to be in the care of the Priory Group here, one about support worker Siobhan Cator and her understanding of 1-1 supervision and refusal to have […]

Peter Seaby’s 2nd Inquest – Conclusion

Peter’s second inquest concluded this afternoon. I’ve more posts in draft which I’ll get to later, that detail the evidence told to the court, but I’m skipping ahead to what the coroner found. I’m not going to report all of the coroner’s summing up, because that would be duplication, but I’ll report the findings she […]

Peter Seaby’s 2nd inquest – April 2018

Peter’s Eating, Drinking and Swallowing Care Plan has been referenced throughout his second inquest (and was also a key feature of his first inquest). There’s a post detailing it’s content, how the Speech and Language Therapist Ms Debbage assessed his swallow, and the staff’s understanding of it here: Peter’s SALT plan ends with clear instructions […]

Peter Seaby’s 2nd inquest – the SALT plan

On Monday we heard from Sally Debbage, the Speech and Language Specialist Lead for Learning Disability Services in Norfolk. She expedited an appointment, visiting Peter at the Oaks and Woodcroft home, within a day of him arriving. She explained that she felt she needed to conduct the swallowing assessment promptly as the “previous directions weren’t […]

Peter Seaby’s 2nd inquest “I have stood on my own in this”

Siobhan Cator, a former support worker at the Priory Oaks and Woodcroft home, gave evidence to the coroner today at Peter’s second inquest. She was questioned for 1hrs 45minutes by the coroner Jacqueline Lake, Mr Cridland for Peter’s family and Ms Sutton for the Priory Group. She ended her evidence with Ms Sutton asking her […]

Peter Seaby’s 2nd inquest – how he came to be in the care of the Priory Group

In May 2018, almost 5 years ago, Peter Seaby died at the Norfolk and Norwich University Hospital, following his admission the previous day from the Priory Group Oaks and Woodcroft care home in Dereham, Norfolk. His cause of death was aspiration pneumonia. In August 2021 Peter’s first inquest took place. I spoke to his sister […]