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 (which I believe we were told was in a separate outlined box) that if there is any deterioration in his eating and drinking skills, for example, coughing on eating and drinking or soon after, or if there is significant unplanned weight loss, that his speech and language therapist should be contacted, or if his case was closed to them he should be re-referred.

In this post I wanted to address the events of April 2018. The first significant incident took place on 15 April 2018. I say it was the first, it was the first discussed in court, and we can not be certain that there were not others as Siobhan Cator commented when asked whether coughing when eating would be recorded in the notes “I’d like to say it was written in the notes all the time but I’m not 100% sure” (see blog post above for more).

On 15 April the notes record in a section about concerns:

At lunchtime Pete choked on a piece of chicken and some cauliflower. Staff removed excess food from Pete’s mouth, patted him on the back between the shoulder blades and asked Pete to cough and spit out anything in his mouth. After coughing up more cauliflower the blockage appeared clear, so staff gave Pete some thickened water to clear his passageway. Pete was then fine. Staff took off any chicken or cauliflower from Pete’s plate and he was happy to continue eating. Pete then finished the remainder of his dinner with no concerns.

The notes state that the Team Leader rang 111 and they were advised to take Peter to A&E to be checked out, which they did. He returned later that day.

The food records for 15 April state Peter had roast chicken, roast potatoes, mashed potatoes with garlic and herbs, stuffing, carrots, cauliflower, broccoli and gravy for lunch.

When Ms Maunder, who recorded the notes for that day [I’ll write another post about record keeping later] was asked about the incident by the coroner, she said she had no recollection of it.

When questioned by Mr Cridland this exchange took place:

SC: So, you wouldn’t have written in notes an account that you didn’t believe at time to be a truthful account?

SM: No, but at the time I’d have been there, it’s a long time ago

SC: So when we see Pete choked on a piece of chicken and cauliflower, that’s likely to be correct is it?

SM: Yeh

SC: [reads] and staff removed excess food from Pete’s mouth, is that correct?

SM: If that’s what I’ve written

SC: Patted him between the shoulder blades, that’s likely to be correct?

SM: If that’s what I’ve written, yes

SC: Do you remember how many backslaps Mr Seaby required during this incident?

SM: No

SC: The 111 documentation refers to him requiring 6 backslaps, are you able to comment in relation to that?

SM: No

SC: You cant remember?

SM: No

SC: Would you not have considered, in those circumstances, this was potentially a serious episode of choking?

SM: Yes

SC: Do you remember being spoken to about this by Deborah Cuzner [Deputy Manager]?

SM: After any incident we’d always have a pep talk or a reminder you need to be more vigilant, please make sure this is adhered to

SC: Do you remember that happening?

SM: Not from memory no

She couldn’t remember if she had prepared the food that day, but said she might have done. The court heard evidence from Siobhan Cator that Sue liked to cook and was renowned for her roast dinners and she felt sure that she’d have cooked the meal.

SC: My recollection was it says it’s Sunday, she [Suzanne Maunder] was renowned for her roast dinners, I wouldn’t get a look in, I’d be the washer upper

No-one could remember who would have prepared the meal for Mr Seaby in accordance with his SALT plan. Ms Maunder said that Peter’s chicken would be cut into Malteser size pieces and then shredded and gravy added. Ms Cator in her evidence said that she wouldn’t have given Peter roast potatoes because they’re too crispy.

Mr C: The roast potatoes?

SC: I’d take out the roasty bits. I don’t think you could have a roast potato and make it mashed

Mr C: You say you did?

SC: I would. I don’t know if others did

Asked by Mr Cridland why the 1-1 time for Mr Seaby at lunchtime hadn’t been recorded, Ms Maunder said she couldn’t help. Ms Cator didn’t know either, but highlighted an earlier entry that day in her handwriting where she’d completed how long she was sat at the table with Peter at breakfast.

Ms Peloe, the Team Leader, said that she was not on duty that day and her colleague Lauren would have been. The court hasn’t heard from the other Team Leader at either of the inquests. The court heard that the 111 transcript of the call made by Lauren that day referred to it requiring 6 backslaps to clear the blockage in Peter’s throat.

There was a lot of discussion about the size of the piece of cauliflower that Peter choked up, it was variously described as the size of a small fingernail, the size of half a fingernail and in court Siobhan Cator described it as a quarter of the size of a fingernail. Some accounts said there was a stalk, some also mentioned a piece of chicken. None of the accounts from the home referred to six backslaps being required.

When Peter’s social worker, Kelly Mann, called the home the following day, about another matter, Deborah Cuzner informed her about the choking incident and the social worker asked her to ensure an incident report form was completed. The social worker’s note of the telephone call with Ms Cuzner said:

Ms Cuzner advised a choking incident had taken place on 15 April 2018 at approximately 13:00. Mr Seaby was eating mashed cauliflower and a small piece, approximately the size of a little fingernail got stuck in Peter’s throat. Peter was unable to clear this himself so staff administered a backslap which brought up the food. Ms Cuzner advised the food was soft and mashed in line with the care plan but she would be checking with the staff member later to request a verbal account of the incident.

Ms Cuzner told Ms Mann that Ms Cator advised her that she believed Peter had inhaled/breathed in the piece of cauliflower and she thought he was coughing rather than choking. When asked about this by the coroner Ms Cator commented that the “only reason I say that is I choked on food before and I inhaled food rather than swallowed… I may have been relating it to my own experience, but whatever, it needed investigation because it was something out of the norm for Peter”.

When questioned by Mr Cridland, Ms Cator got upset as she recalled what happened that day:

SC: I do remember, it sounds horrible but it was a trauma to me, he was someone’s loved one and it was horrible

Mr C: How was it a trauma?

SC: It’s someone’s loved one choking. It stayed with me

Mr C: So it wasn’t just coughing on food, it was more serious?

SC: Yes, it was a funny sound, it didn’t sound right to me.

On questioning from Mr Cridland, Deborah Cuzner agreed to his suggestion that the incident on the 15 April 2018 warranted further investigation:

SC: its fair comment isn’t it, on the information contained in these records, that this incident required further investigation?

DC: Yes

She also confirmed that there were two pages at the end of the incident report form that were never completed.

SC: Last page, sections for manager to note whether staff debrief undertaken… whether documented… whether highlighted training needs… lessons learned… provide comments

DC: Yes

Mr Cridland asked in turn whether these things had happened, and Ms Cuzner confirmed that no staff debrief took place, the incident wasn’t considered further so no training needs were identified, and no lessons were learnt from the incident.

Ms Cuzner said as Deputy Manager she wouldn’t have access to the final two pages of the incident report form, only the home manager would. She thought she’d notified the Area Manager but she couldn’t be certain.

Kelly Mann, Peter’s social worker made contact with a Speech Therapist whilst the incident report was considered and a decision made as to whether a safeguarding inquiry needed to be opened. On the basis of the information provided to Norfolk County Council they decided it did not warrant a Section 42 Inquiry.

The incident report form, as described by Mr Cridland said that “Peter had potentially choked, but it was a relatively reassuring account associated with it, small piece of food, prepared in line with the care plan, self limiting, only needed one back slap”.

Asked by the coroner whether Norfolk CC may have made a different safeguarding inquiry decision if all the information were made available to them by the home Ms Mann felt it would have needed more investigation, before a decision could be made.

C: So on the basis of what you were told, no safeguarding concerns, on the basis of seeing these records with reference to chicken, cauliflower, excess food in mouth, supervision not completed on form, would that have? How would that have affected your view of safeguarding concerns, are you able to say?

KM: It’s difficult looking back on it without being able to make further inquiries.. each occasion would look at what is proportionate and what is harm caused… even if didn’t meet safeguarding, if 1-1 wasn’t provided would look more closely, having conversations about why not provided and reinforcing that’s what’s been commissioned to be provided. Sometimes part of ongoing work under Care Act even if not a Section 42 inquiry

C: I want to be clear what difference would that make?

KM: The 1-1 or the food in his mouth?

C: What you’re seeing in care records, and what you were told, at least would that require further investigation?

KM: Yes chicken and cauliflower is more than just cauliflower, and it doesn’t say here how food was prepared, doesn’t say whether they followed mashed diet or not. I’d be wanting to know a little bit more about that.

We know that no-one at Oaks and Woodcroft contacted the Speech Therapy Team after this incident. One of the red flags on the SALT care plan.

We also heard evidence this week, read to the court, of an overview of Peter’s attendance and appointments at his GP surgery. He joined the surgery on 1 March 2018, three months after he was moved to Oaks and Woodcroft. One of the appointments that the usher read out related to weight loss.

Peter was seen by a doctor at the surgery on 25 April 2018 for query weight loss “neither the patient or the carer was able to say how much weight loss, or for how long weight loss was noted”.

So in April we know that Peter’s swallow may have deteriorated, there was certainly a serious swallowing/choking incident, and we know that he had unexplained weight loss, but we have heard no evidence in court that the requirement in the SALT plan for the team to be contacted and alerted to these concerns was followed.

Peter’s inquest is expected to conclude at 2pm this afternoon.

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