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 as clear as they could have been, so I felt was a need to do a new assessment with some urgency”.

The coroner asked Ms Debbage to talk through the plan, and she did, explaining how she conducted the assessment and also how the swallow works. The plan was referred to throughout the inquest, and some of the key aspects relating to Peter was that he had no teeth, he had difficulty with residue building up that he could not clear, and he needed the consistency and texture of his food to be altered accordingly. Ms Debbage explained that the rules and guidance has changed since Peter’s death in 2018, but she explained that recommendations at the time were given in relation to Peter’s posture when eating, equipment that might help, how his food should be prepared, foods to avoid and the risks of non adherence to the care plan. Ms Debbage conducted Peter’s assessment in the company of Deborah Cuzner, the Deputy Manager of the home.

Ms Debbage explained that for her assessment she wanted to see Peter chew to see what his abilities were, so he had a white bread cream cheese sandwich, with the crusts removed, cut into 1.5cm pieces. She explained that size is chosen because if something goes wrong it should still pass through an adult airway, with moisture and gravity. Peter’s swallow wasn’t working as a normal swallow was, his lips had reduced muscle tone and reduced movement. She explained that you can have exceptionally hard gums even without teeth that can mash food into tiny pieces but to do so you need to have movement in your jaw, and enough pressure. Mr Seaby didn’t have enough muscle strength, his movement was predominantly an up and down chew but there was no rotation of his jaw, and his cheek tone was low. He also had an open mouth posture, even when chewing.

She went on to explain that in order for Peter to eat safely, the size and texture of food would need to be modified; by making the particle size smaller and adding moisture it would make the bolus cohesive and effectively simulate a normal chew.

The second stage of the assessment related to oral transit and she assessed that Peter didn’t have a strong enough tongue movement to clear the blade of his tongue, and his reduced strength and range of movement in his tongue was resulting in residue after he’d swallowed.

Ms Debbage also assessed Peter drinking, and he required a dysphagia mug and thickener to be added to fluids. She explained that the mug would keep his chin tucked when drinking and that thickener slowed the drink down, allowing his brain more time to process that he was drinking and ensure his larynx was shut and his airway protected when drinking.

“With regards to food it was clear if bigger bits than I was recommending, because he wasn’t able to chew and transit appropriately, any bits larger than recommended could and would make him cough…. bigger pieces were causing him more problems and causing him to cough”

She explained that once swallowed and out of the mouth there is no way of getting back except to cough or vomit, if food goes down the wrong way. She explained therefore that Peter required a soft texture to his food, with moisture, which then needed to be mashed to reduce the particle size, so he ended up with a soft, moist, mashed diet.

She told the coroner that after her assessment she stayed in the home and completed his care plan in situ, she then emailed it to Deborah Cuzner who printed it and she signed it. She also printed a prescription request letter for the GP that she delivered when she left, and in the interim advised staff to use a tumbler or teacup for Peter’s drinks (something with a wide brim) and she left the home with a tin of thickener for immediate use.

The coroner took Ms Debbage through her findings, that included that Peter did not have capacity to understand the decisions of the assessment she’d conducted, or the nature of consequences of dysphagia and the reasons for adaptations. As a result of this she was clear that “all staff and carers who support Peter” were responsible for the implementation of this eating, drinking and swallowing care plan.

With regards to the consistency and texture of food the requirements were:

  • Soft, moist, mashed consistency
  • Meat should be cooked until soft and mashed, if staff were unable to mash then the meat should be pureed
  • Mince should be cooked in fluid and not dry fried

The coroner asked what mashed meant and Ms Debbage explained that it was mashed with the back of a fork, so food could fit through the gaps in the fork.

There were only two exceptions to this:

  1. Sandwiches. Which Peter was able to have if they were white bread, had no crusts, were cut into 1.5cm pieces and had a moist filling eg tuna mayonnaise or egg mayonnaise
  2. A maximum of 5 Quavers broken into 1.5cm pieces.

The plan stated the reasoning for why only 5 Quavers as these being give for pleasure and it being the least restrictive option. He could not have more than 5 because Peter’s swallow got worse the more he ate, he experienced fatigue and residue built up, which could overspill into the pharynx, and would cause coughing as his body tried to clear it. She was explicit that it was only Quavers, and not Wotsits or other crisps that he could have.

There was a list of foods to avoid, including food of mixed consistencies eg cereal with milk. There was also a requirement for a 10min break between food and drink, between the first mouthful of one and last mouthful of the other and Peter should remain supervised for 10mins in the eating position after the last mouthful. Ms Debbage explained to the coroner why that was:

Coroner: I want to look at mixed consistencies, is that all cereals with milk?

SD: yes, or yoghurts with bits of fruit in it. Any harder texture with thinner texture where your brain has to tell your swallowing mechanism, the brain tends to focus on one texture at a time. If you have a delayed swallow your brain could be thinking about one consistency and not prepared for the other. That’s why the 10 minute gap between food and drink…. it gives Mr Seaby the chance to clear residue from his mouth with repeat dry swallows before having the drink, or vice versa so he could have drink first and food after.

C: would cake have to be mashed?

SD: yes everything would except the exception foods, which were bread and Quavers.. Avoid biscuits because biscuits have different consistencies… only time would ever have accepted change in this was if the biscuit had been soaked and could then be mashed.

The plan included the advice if Peter coughed to not rub his back, but allow him to resolve it naturally and get him as upright as possible. It said to only pat him on his back as part of an emergency procedure of backslaps. Ms Debbage explained why:

SD: If you rub or pat someone’s back during the process can make person do a sharp intake of breath so sucking it down into lungs not out… if he’s coughing he’s already trying to clear himself, but if it’s an emergency go into backslaps

C: so cough first, then if does not resolve go into backslaps?

SD: Peter didn’t have a voluntary cough, so you couldn’t ask him to cough and he’d do it, he’d just cough involuntarily

C: OK. Supervision you’ve said 1-1 supervision including 10min gap and 10min after last mouthful?

SD: yes because of residue, is still risk of aspiration if goes down into airway, so we’re trying to get him monitored at that time when he could be at risk.

C: by supervision. One to one, what do you mean by that?

SD: someone there, right beside you, watching

C: is there a distance you need to be away?

SD: No, because 1-1 they should be formally responsible for him. Norfolk County Council had put funding in for 1-1, so they don’t leave that person’s side the whole period of time, don’t get distracted by something else or supporting someone else. Their role is to support that person throughout their eating and drinking…

C: and beyond?

SD: yes for the 10mins

C: so full eyes on?

SD: yes

Asked to explain the risks that she’d set out Ms Debbage explained that all of us are always at risk of aspiration or asphyxiation so that’s why the care plan referred to low risk and not no risk. It stated that the current risks were:

Aspiration – risk low if care plan is adhered to. If care plan not adhered to risk is moderate.

Asphyxiation – risk low if care plan is adhered to. If care plan not adhered to risk is high.

The coroner then outlined what else was included in the plan:

C: you say to re-refer if eating or drinking skills deteriorate, if he develops frequent chest or urinary tract infections, if there is significant unplanned weight loss, or if capacity changes. In those instances you’d expect?

SD: yes, I would expect them to contact us and if we’ve closed the case to re-refer

C: you ask that this be attached ti his health book and hospital passport, and then you’ve written in capitals IT IS ESSENTIAL THAT THIS CARE PLAN IS ADHERED TO, AS FAILURE TO DO SO COULD RESULT IN ASPIRATION OR ASPHYXIATION WHICH ARE POTENTIALLY LIFE THREATENING and it then says Section 44 of the Mental Capacity Act states it is an offence to wilfully ill treat or neglect a vulnerable person who lacks capacity.

SD: yes

There was more questioning about who should sign the plan, the answer being anyone who was supervising Peter eating or drinking. The Coroner then took Ms Debbage to some examples of food recorded being given to Peter asking for her opinion on it. It was impossible for her to say whether they met the requirements of the care plan on most occasions because the descriptions were too vague. It was also unclear what the 1-1 time accorded to as it didn’t match the required supervision time for the foods and drink given to Peter.

Despite the opaque record keeping, there were a number of direct contraventions to her plan when taken to records including brown bread sandwiches and Skips being given to Mr Seaby:

SD: no, that’s not okay. I hadn’t advised that, I’d advised only Quavers. It’s about how they uptake moisture from your mouth which is why Quavers and Wotsits were looked at.

There were two incidents that a lot of the questioning centred around, one on 15 April and then one on 21 May 2018, the day before Peter died. The coroner asked Ms Debbage for her view of the first:

C: page 967 relates to that day. It refers to roast chicken, roast potatoes, mashed potatoes, stuffing, carrots, broccoli, cauliflower and gravy. No time in supervision, but it says he choked on some chicken and cauliflower. What happened, whats your comments with regards to this page?

SD: I probably wouldn’t have viewed it as choking, would have viewed it as a potential aspiration. The fact that a piece of something has been coughed up, clearly went to laryngeal level potentially to make him blow it back up out

Going through where he was asked to cough and spit out anything in his mouth, from the mental capacity assessment I completed I don’t think Peter would have been able to follow those instructions and have completed that.

He would have needed 10 minutes between food and drink, if you give drink too soon you’re at risk of carrying residue and increasing the risk of aspiration.

On the 15 May it was recorded that Peter was coughing at meal times two meals running. Ms Debbage felt it could be due to him having quiche for lunch, which depending on how it was cooked could be dry crumbly consistency, and therefore to be avoided. She also highlighted that the fact it was happening two meals running could indicate a deterioration in Peter’s skill level. The coroner checked that the care plan suggested in that instance the SALT team should be contacted and she agreed.

The coroner then took Ms Debbage to the recording of the events that took place on 21 May 2018, that eventually led to Peter’s death the following day, and asked her what her thoughts were.

The records for that day between 1pm and 7pm variously described Peter as coughing while eating, bringing food back up, clearing his throat, bringing up a large amount of phlegm, cough up anything he ate or drank, coughed/sicked it back up again, brought that (weak squash) back up and being sick twice.

SD: I’ll comment on the whole. I think he probably aspirated or had asphyxia going on at lunchtime, and that then continued. Potentially he had some residue somewhere.

C: at lunchtime?

SD: yes incident at lunchtime, onset of first cough noted that he coughed when eating and brought some food back up

C: [missed start of the question] is this the larynx?

SD: anywhere in the pharynx, throat. The larynx is where vocal chords are housed, if you go below that that is aspiration. Anything above or in the pharynx can work as an irritant. Coughing blows that back up. If it goes below the level of the vocal chords then you get coughing accompanied by vomiting, because you’re then trying to get it out of your lungs and power increases, can then induce vomiting.

If you’ve got residue it will produce mucus, because then you have a foreign body, so there’s a build up of mucus … so residue potential sounds to me, with build up of phlegm around it.

Later when questioned by Mr Cridland, Ms Debbage confirmed that her view, on the balance of probabilities, was that Peter’s ill health on 21 May all went back to the lunchtime meal. She said that the fact he wasn’t able to swallow yoghurt, which is one of the easiest things to swallow, led her to believe something had changed. She said that could have been due to non-adherence to his SALT care plan, or it could be that something had changed physically with his swallow.

The pathologist in his evidence that was read to the court earlier on Monday described finding “a large circular piece of carrot” that he estimated to be approximately 2cm in diameter in Peter’s throat. The coroner took Ms Debbage to the photograph from Peter’s post mortem report that showed a slice of carrot that was found in Peter’s throat and asked her whether she were able to say what the sequence of events with regards to Peter had been. Her response “the only thing I am able to say is that diameter piece of carrot doesn’t follow the care plan”.

Ms Sutton whilst recapping Ms Debbage’s answers led to this discussion:

ES: You also said the carrot was larger than it should have been, 1.5cm?

SD: the carrot should have been mashed through the tines of a fork. It was only the Quavers or bread that were allowed to be 1.5cm, because they’re exceptions. I take liability over that because I’ve seen them eat it. Everything else must be soft, moist, mashed.

ES: through the fork?

SD: yes

Later she returned to the carrot:

ES: finally, this is my last point. In relation to the carrot and potential asphysiation as opposed to aspiration, what we have from independent expert in this case, is that it is incredibly unusual for a patient to have a large slice of carrot lodged in their throat and not be significantly distressed by it

SD: I can comment that some residue can cause some people an extreme amount of distress…. sometimes it depends on the person, from my experience, as to how they communicate that level of distress

ES: ok if you can’t comment that’s fine, I have no further questions, thank you very much.

Of course Ms Debbage had commented, that how person’s show distress is very individual and it depends on how they communicate.

Throughout the week each member of staff from the home was asked about their understanding of Peter’s soft, moist, mashed diet and his SALT care plan. I think its fair to say that knowledge, and practice, appeared variable.

On Tuesday morning Ms Gemma Peloe, a Team Leader, when asked by the coroner what she understood a soft, moist, mashed consistency to be, responded “mashed potato would be my personal opinion on it, how you’d do mashed potato”. When questioned by Mr Cridland she said she had no specific memory of signing Peter’s SALT plan. Ms Sutton attempted to clarify her understanding of Peter’s diet:

ES: You referenced your understanding the type of diet Mr Seaby required was soft, moist and like mashed potato. Is another understanding that its food that could go through the bars of a fork as described by other witnesses?

GP: yes. When I think mashed the first thing I think of is mashed potato, so would be mashing with a fork because there was no potato masher

Which is somewhat surprising given the number of meals referenced that included mashed potato, and that meals could be prepared for anything up to 6 residents.

On Tuesday afternoon Ms Deborah Cuzner gave evidence to the court. She was a Deputy Manager at the time Peter was at the Oaks and Woodcroft, and now works as a support worker at the home. Asked how she ensured that meals were prepared in accordance with the SALT care plans, she said that was down to the staff and Team Leaders.

C: Did you ever do anything to ensure that first of all the food did comply, and secondly that the Team Leaders were checking it complied? As Deputy Manager?

DC: I did walk around, obviously bits and bobs, I do auditing, spot checks but there’s nothing recorded on that so I cant prove that

C: Did you ever check meals were prepared in accordance with the care plan?

DC: I didn’t check the food no, but I looked at the food yes

C: What did you look for when you looked at food?

DC: I looked at the food but I did not go through the food

C: Did you check it complied with a particular residents care plan?

DC: Yes because I knew what care plans was

C: Did you ever have any concerns food wasn’t prepared in compliance with the care plan?

DC: No

C: How often would you conduct spot checks?

DC: Unfortunately not very often, about once a month, to go round

C: With regards supervision, how did you ensure residents were supervised in compliance with their care plans?

DC: Unfortunately that was down to Team Leaders because I was more office based at that point

C: Did you consider as Deputy Manager that was part of your responsibility?

DC: Not trying to cover myself I’d only been a Deputy Manager for not too long, was still learning my role

C: did you consider ensuring residents were appropriately supervised was part of your role?

DC: Back then I just assumed they were being supervised. Team Leader was part of their role to ensure day to day running of the floor was being done.

On questioning from the coroner Ms Cuzner agreed that meals and snacks given to Mr Seaby did not comply with his SALT care plan, including brown bread, wotsits, sliced banana and that the supervision time given to Peter at mealtimes didn’t comply with his care plan. The final question from the Coroner for Ms Cuzner was:

C: when after Peter’s death did you look at his care plans, was it immediately after?

DC: We were told Mr Seaby died of natural causes so I didn’t look at those support plans because I didn’t think to.

C: You didn’t look at them when he was in hospital for instance?

DC: I didn’t no.

Mr Cridland picked up on this point in his questioning:

SC: am I right to understand the care home itself carried out no investigations subsequent to Peter’s passing?

DC: No, because it was natural causes

SC: it wasn’t conveyed to you the medical cause of death was aspiration pneumonia?

DC: No, it was natural causes


SC: were you not concerned when you did receive that information that given his SALT care plan his passing might have been related to the food he’d been provided at the home that day?

DC: No

SC: that didn’t occur to you?

DC: No, no

On Wednesday, a support worker, Suzanne Maunder gave evidence. Asked whether SALT plans would be kept anywhere other than in a locked cabinet in the office she told the coroner “from my recollection back then I didn’t know, but apparently there was some kept in the kitchen”. Asked by the coroner if she remembered Peter’s SALT plan being distributed she said she did not “it must have been but I don’t physically remember it”.

The coroner took her to Peter’s assessment and asked if she recalled the difficulties he had, she did not. Asked if she remembered the requirement for Peter to be sat with his feet on the floor to aid his posture she said:

SM: They were all sat at the dining room table anyway, that’s how they’d be sat. Do I remember it? No, but that’s how they would be sat anyway

C: would you assure yourself that the residents were sitting straight up at the table with their feet on the floor?

SM: Yeh yeh

C: consistency and texture, you’ve referred to this, a soft moist fork mashed diet… meat cooked until mashed, if couldn’t be should be pureed. Is that your recollection of Peter’s diet?

SM: That’s how soft moist mashed diet would be

C: Is that your recollection of Peter’s diet

SM: Well no. I don’t remember, but anyone who was on a soft moist mashed diet, that’s how it would be.

C: Do you remember Peter being on a soft moist mashed diet?

SM: Yes I do

C: do you recall two exceptions to that, first sandwiches, providing white bread and no crusts cut into 1.5cm pieces with moist filling, other exception is 5 maximum Quavers, is that your recollection of requirements for Peter?

SM: I didn’t know about the Quavers at the time, but it was brought up at the last inquest

C: so did you know about Quavers?

SM: I didn’t know anything about the Quavers but on a soft moist diet any of the other residents would have what we’d class as soft crisps, corn style crisps like Wotsits, Quavers, veg stick things that dissolve in the mouth

Asked what her understanding was with regards to Peter’s needs in relation to supervision when eating she said:

SM: Just someone to watch over him whilst he was eating so he wasn’t left alone

C: So someone to watch over him, in the same room?

SM: yeh yeh

C: Sitting next to him?

SM: If possible, but then that would be as 1-1 but I didn’t realise Peter had 1-1 for eating, as long as he was supervised

C: What I’m trying to ascertain is what 1-1 of Peter meant

SM: About me and you away

C: So 10 feet away, about that?

SM: Yes. Because he was basically at risk of choking so someone was available if there was an incident. Peter was usually a good eater, there have been a few incidents brought to light since, but there wasn’t really any concerns.

When questioned further by the coroner Ms Maunder agreed that Peter was not being provided with 1-1 supervision on the 21 May 2018. When the coroner questioned her about her understanding of the risks of not adhering to Peter’s care plan this was said:

SM: Well yeh its all there, I’m assuming, I must have read it at the time. Anybody can choke on anything at any time cant they, I’m not trying to make light of the situation because obviously it’s a serious matter

C: well some people are more at risk of choking on anything at any time

SM: Yeh that’s why the care plans are in place and we have to follow them, I am aware of that

C: were you aware if the care plan was not adhered to could result in aspiration or asphyxiation?

SM: At time I wasn’t aware of the term aspiration, what it meant, but obviously I knew he was at risk of choking

C: and were you aware that choking, or anything else like that, could potentially be life threatening?

SM: Yeh


SM: I’d never really heard the term aspiration until what happened to Peter Seaby. I mean I’d read it but didn’t know, I mean I knew if someone choked they could die

C: OK at that time you didn’t know what aspiration meant

SM: No, and when I was told it was aspiration pneumonia I didn’t know what that meant either

Ms Maunder told the coroner that she could not recall signing Peter’s SALT care plan. On further questioning from Mr Cridland she agreed it was possible she had not seen it.

SC: So you think its possible you didn’t see the SALT care plan but were told instead he was on a soft moist mashed diet?

SM: It’s possible yes

SC: Am I right to understnad when you’ve been taken to the SALT care plan, and the learned coroner took you to it, and you’ve been taken to it before including by myself at the last inquest, that doesn’t jog your memory?

SM: No I’ve seen lots of SALT plans, I don’t specifically remember Peter’s

Wednesday afternoon the court heard from another support worker, Siobhan Cator. She described talking to Sally Debbage, the SALT therapist after she’d conducted her assessment of Mr Seaby, because she was fascinated by the assessment process. Asked of her understanding of his SALT care plan she confirmed to the coroner that she knew it in detail:

C: What was your understanding of soft moist mashed?

SC: Whatever was cooked had to be completely mashed with a fork and then liquid added to it to make it the right consistency

C: what was your understanding with regard to meat?

SC: If could be cut really small, the first person would cut off the joint of meat and then we’d make sure it was meticulously cut and mashed. Or I should say I would, I would feel it was my responsibility.

C: Yes and that’s the position of the plan.

She told the coroner if she had any concerns about Peter coughing when eating or drinking she’d report them to the Team Leader, and if she weren’t available to Debbie Cuzner as the next person higher up. Asked how that was done, in writing or verbally she replied:

SC: I’d like to say it was written in the notes all the time but I’m not 100% sure, but you’d verbally say Peter has been coughing today while eating or coughed today while drinking a certain drink

She wasn’t able to recall signing Peter’s SALT care plan.

Peter’s second inquest continues.

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