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 Karen, and brother Mick, before that inquest to get to know a little about Peter. You can read about him and their life as a family here: Peter Seaby hated carrots.

Peter had lived happily and healthily in the care of his family for 63 years before he was placed at the home by social workers from Norfolk County Council. On Monday we heard evidence, a statement that the coroner read onto the record, from Marcia Solloway-Brown, a Practice Consultant at the Norfolk County Council Southern Learning Disabilities Team. In her statement she described how she line managed a team of social workers, and she had “over 40 years experience of supporting people with learning disabilities and their family carers”.

She described how she came to be involved in Peter’s life and offered her views on the care he received at home:

“It was apparent that Karen Seaby cared very deeply for Mr Seaby and had done for many years” then later “as a result of Mr Seaby’s dementia and his increased needs it was apparent Ms Seaby was struggling to provide the care that Mr Seaby needed”. She continued:

“Miss Seaby was observed to have her own needs. A number of similar concerns were raised by different professionals. I made an unannounced visit to Mr Seaby and his sister, Karen, on 28 November 2017, together with Liz Gard, the learning disability nurse, to share the concerns about Mr Seaby’s care, his needs and health and wellbeing. We had identified a respite facility that could meet Mr Seaby’s needs and the staff for this provision were on standby to transport him to respite. … Miss Seaby was understandably upset”.

Marcia Solloway-Brown then went on to describe how the Priory Group home, Oaks and Woodcroft, had been identified as suitable. It came down to availability of space, and whether the Quality Assurance team had a block on placements as would happen if they had serious concerns. There was no block, so despite the Oaks and Woodcroft being some distance from Karen and Peter’s home, it was deemed suitable. She described how the placement was identified and funding approved before any discussion took place with Peter and Karen. She also mentioned that a nursing colleague had a relationship with the home and had recommended it.

Kelly Mann, Peter’s social worker, in her live evidence to the court on Monday confirmed that Peter’s community nurse Liz Gard had recommended the home to the social workers, and she had no concerns about the care Peter was receiving there.

The court also heard statements from Karen and Mick Seaby, Peter’s sister and brother on Monday. They stated that they did not agree with the suggestion that Peter had dementia and that there had been no assessment or formal diagnosis. Karen Seaby stated:

‘Peter was removed from my care by Marcia Solloway-Brown and Liz Gard of the Learning Disabilities Team…. he was taken to the Oaks and Woodcroft care home for two weeks respite care. This was against our wishes as a family and in our view against Peter’s will’.

In her statement Karen described visiting the home and trying to bring Peter home, but the care home told her she could not due to a court injunction. Mick Seaby’s statement suggests when a solicitor investigated the care home did not have the correct paper work or authorisation in place to stop Karen removing Peter at that time, although Norfolk CC sought it from the Court of Protection days later.

Towards the end of her statement Karen commented on the LEDER report conducted after Peter’s death. She said:

‘I also have concerns about the LEDER review as it contains a number of inaccuracies and I do not agree with a lot of the information that was passed to the authors of the report by Peter’s community nurse, Liz Gard. Liz didn’t know anything about Peter, me or our family’.

Notes

1. I’m not live tweeting this second inquest as I’m concerned about the reliability of Twitter. Instead I will blog about certain key issues when I can, and most of the reporting is likely to follow after the inquest concludes.

2. Peter’s first inquest was quashed in January last year:

The grounds of challenge were that, in making the two determinations regarding the applicability of Article 2 and the rider of neglect, the Defendant had erred in law and/or acted irrationally in that she reached a conclusion that was not reasonably open to her on the evidence and had she properly directed herself to the law.

Upon receipt of the family’s letter before claim and Statement of Facts and Grounds, which set out the basis of the challenge, neither the Coroner nor any of the Interested Parties to the original inquest contested the application.

On 17 January 2022, the Court handed down an Order in the terms sought, quashing the conclusion and record of inquest of the first inquest and ordering that a fresh inquest be held by a different Coroner.

3. BBC Coverage of Day One is here

4. BBC Coverage of Day Two is here