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 made within it.

With regards to Peter’s SALT plan, the coroner detailed its contents and the assessment conducted by Ms Debbage. She said some staff said that they had signed a copy, others were unsure. She found:

No signed copy has been produced in evidence at this inquest.

She went on to say:

Ms Maunder gave evidence she didn’t remember Mr Seaby’s SALT plan being kept in the kitchen, she said she vaguely remembered it being sent round. She said she was aware he needed a soft moist mashed diet. She did not recall him only being allowed Quavers, she referred to him and other residents being allowed soft crisps, corn style like Wotsits. It was Wotsits which had been specifically trialled and were not allowed by Ms Debbage. Ms Maunder referred to Peter’s diet being the same as any other residents’ soft moist mashed diet. She said it was possible she’d not seen Peter’s care plan. She said she was now aware Peter’s supervision was 1-1, as at May 2018 she said she understood he required someone to watch over him so he was not left alone, and to be kept in view, some distance away, she referred to the distance between the witness stand and my desk. She did not understand aspiration until following the first inquest.

Ms Cator’s evidence was she was told 1-1 supervision meant the carer could be 12ft away from the resident.

Care staff gave evidence it was members of staff on shift who’d determine who would do what with regards to preparation and supervision of food, including 1-1.

There was no written rota, and no written records made, as to who would carry out these important tasks.

Ms Cuzner referred more than once to this approach being informal, to provide a home from home feeling. She referred to this informal approach working. This was echoed by Ms Peloe who referred to providing a home from home environment, a comfortable environment.

With regards to supervision of Peter the coroner said:

There were occasions when 1-1 was not completed, it is not clear from the evidence whether this was due to poor record keeping, or whether Peter was not supervised at all.

There were occasions where times given did not allow for 10min after meal or for 10min between food and drink being given [example given]

Gemma Peloe, Team Leader, and Ms Cator said the time recorded only included when the resident was actually eating or drinking and not the two additional 10min periods.

Deborah Cuzner said this was not how the care plan and daily records were to be completed.

With regards to the records of the incident on the 15 April 2018 the coroner said:

Ms Maunder said although her initials are at the bottom of this record, and it was her hand writing, anyone could write the notes. She said she couldn’t recall writing the notes. She said sometimes folders were put on the table in the dining room for others to complete. Sometimes a carer would be asked by someone else to complete them… sometimes that related to the home they were not actually based at.

Discussing the evidence given about that incident the coroner said that she was satisfied that the evidence given in the records was more serious than that which was provided verbally to Ms Mann, the Norfolk CC social worker, and in the submitted incident report form. The coroner said due to a failure to speak to all staff involved, to look at relevant records, or to conduct a sufficient investigation “there is no clear evidence as to what actually occurred on the 15 April 2018”.

The incident report form was not competed with regards to debrief, lessons learned, or the need for any training. The coroner summarised that Ms Cuzner [Deputy Manager] said it was to be completed by the manager, and there was not one in place at the time. The coroner made inquiries with the care home, and it was stated there was a manager in place at the time. No completed form was available. Witnesses did not recall any debrief. The coroner found:

I am satisfied following 15 April there was no debrief, no investigation and no learning.

No consideration was given as to whether Peter’s swallowing had deteriorated and whether his SALT plan needed to be reconsidered.

The coroner recapped the events of 15 May 2018 when Peter was reported as developing a cough throughout his meal at lunchtime when he had quiche, carrots and broccoli, and again later at tea time when he was given a sandwich and developed a cough again. The records suggest that he was being supervised by Ms Cuzner on that occasion.

Ms Cuzner said Peter often coughed to clear his throat and it raised no concerns for her. Although she completed records for that day she did not look at the earlier entries on that day which included sliced banana being given to Peter.

The coroner found that this was not in accordance with Peter’s SALT care plan, and did not comply with time required for 1-1 supervision.

Ms Debbage when taken to the notes had two possible explanations, one that the quiche he was given was dry and crumbly and that caused the coughing, or secondly as the cough occurred two meals running that it may be an indication of a deterioration of Peter’s swallowing skill level.

The coroner then turned to the events of 21 May 2018. Peter was given shepherd’s pie and veg for his lunch that day and it was not specified what vegetables he was given.

“I find Peter was not given 1-1 supervision at this meal which is in breach of his care plan”

The coroner revisited Ms Maunder’s evidence from that afternoon that she remembered Peter coughing and a lot of phlegm coming out, enough to ask someone to get a towel. She said she told Ms Peloe. Ms Peloe said that she heard Peter making gurgling noises.

Ms Cuzner went over to Woodcroft to see Peter and saw him sat with Ms Maunder. She said he was ok in himself, she was not aware he’d been bringing food back up and she did not look at the daily records.

The coroner then moved onto the doctors appointment that was made for Peter that afternoon. He was taken to that appointment by Rio Horne, a support worker who had been working in the other bungalow, Oaks, that day and who said she’d not spent much time with Peter. She didn’t take the care home records with her to tell the GP what the concerns were. Peter was unable to tell the doctor himself and so was reliant on others doing that for him.

Dr Garalevicience said that she firstly relied on what the support worker told her, that Peter was struggling to swallow that day and was bringing up phlegm. She said she specifically asked if Peter was vomiting and was told quite clearly he had not vomited. Dr Garalevicience examined Mr Seaby, including listening to his chest and at that point there was no signs of aspiration. On that basis she made a working diagnosis of reflux, and told Rio Horne to seek further medical advice if Peter’s condition deteriorated.

Dr Garalevicience said if she’d been told what was in the care home records from 13:00 up to the time of her appointment, or if she’d seen the records herself, then her management of Peter would have been different…. that he was unable to swallow was a concern, she’d have trialled him with drink and spoken to the hospital… She would have concern he might aspirate. She said coughing and vomiting can increase the risk of aspiration and would need to act quickly. She said admission to hospital was the likely outcome.

That evening April Meddler and Per Oberg were the two night staff on duty. The coroner commented on the fact that Ms Meddler had been in post as a support worker for 6months and received no first aid training, and that Per Oberg was even less experienced.

The coroner then addressed the discrepancies between Ms Meddler’s written statement, the timings of the 111 and Out of Hours GP telephone calls, and her oral evidence to the court. Records at the home stated that a call was made to the 111 service at 19:45 and that April Meddler made a second call later.

I do find the information in the second call with the Out of Hours GP reflected information provided in the first 111 call, and that the evidence provided in the first written statement of Ms Meddler did not reflect what was in the 111 call and Out of Hours GP records.

Therefore the evidence accepted by the coroner was that the first call made to 111 was at 20:53, and Ms Meddler was told the call would be returned within the hour, by 10pm. Records showed that the Out of Hours GP service tried to call back at 21:16 but the line was busy. They then returned the call again at 22:45.

On that call, about 2 hours after the original call, in response to the doctors questions Ms Meddler checked Peter’s daily notes and said Peter had been sick since about lunchtime, 1pm and brought some of his food back up. She said his stomach was still heaving, his hands were purple, he was holding his stomach but not his chest. She said he looks awful if I’m honest, he doesn’t look himself at all, he’s got quite a greyish complexion. She said he wasn’t clammy but his chest was cooler than normal, but not cold and his feet were purple.

The GP said an ambulance needed to be called for Peter, which Ms Meddler did immediately. The coroner found there was no chasing call made by Ms Meddler to 111 during the intervening period between the first call at 20:53 and that conversation at 22:45.

The ambulance service arrived on scene at 23:08 and Peter was taken to the Norfolk and Norwich University Hospital. On admission he was unconscious, and he did not regain consciousness. He was diagnosed with aspiration pneumonia, initially treated with antibiotics, before the decision was made with Peter’s family not to escalate him to ICU given his poor prognosis, and he died the following day, with his family at his bedside.

The coroner went on to outline the slice of carrot found in Peter’s throat at post mortem. The pathologist gave the medical cause of death as 1a) aspiration pneumonia, and part 2 significant contributory factors as Down Syndrome, Cirrhosis of the liver, and Cerebral infarction. The coroner stated:

Aspiration pneumonia on its own, with no concerns, is a natural cause of death. This is recorded by the pathologist in the preparation of his report.

In this case there are several concerns, with regard to how and in what circumstances Peter came by his death.

It is clearly not suitable for a case of natural causes. It would not reflect the evidence we’ve heard over the past 5 days.

She said that a narrative conclusion was agreed by the lawyers of Peter’s family and the care home, Priory Group, although the content of the narrative was not agreed. Norfolk County Council were neutral. The coroner said she’d taken into account submissions from the family and the Priory Group, and had considered the case law , the Chief Coroner’s Guidance No 17 and the Galbraith Plus test (that her conclusion must be based firstly on sufficient evidence, and secondly must be safe for her to reach that conclusion based on the evidence before the court).

She said:

With regard to the slice of carrot in Peter’s throat, I am satisfied on the balance of probabilities this was eaten by Peter at lunchtime. Vegetables given were not specified in the written records, witnesses couldn’t remember, however there is no evidence this slice of carrot could come from anywhere else.

On this basis satisfied this is when Peter ate the slice of carrot. It was a slice, it was not mashed. I find that does not comply with the care plan.

She outlined that the evidence she’d heard (from the pathologist) was uncertain as to the significance of the carrot. It may have been in the region of the larynx inlet and it may have caused a degree of airway obstruction that may have contributed to Peter’s death; it may have been pushed further down his throat by the throat pack inserted at Last Offices; or it may have been where it was at the point of autopsy, in the throat and not occluding the laryngeal inlet.

Either is equally possible. I have no other evidence in this respect and am unable to make a finding whether it caused any obstruction and in this way contributed to Mr Seaby’s death.

With regards to aspiration she considered the evidence of Dr Bint, the GP expert, Dr Lonsdale’s evidence and that of Ms Debbage, who all felt it likely that the carrot hadn’t made it into his airway and probably did not contribute to the development of aspiration pneumonia, instead the view was that it was likely caused by Peter aspirating vomit.

I am of the view the aspiration was not directly caused by the carrot going into the lungs and the carrot did not cause the aspiration pneumonia.

The carrot was not however prepared in the way specifically laid out in the SALT care plan. It was at lunchtime 21 May 2018 when Mr Seaby first coughed and brought some food back up on that day.

Dr Lonsdale was of the view it was most likely the significant episode of aspiration occurred during his episode of coughing/choking at lunchtime. He goes on to say the timeline of deteriorating some hours later with established aspiration pneumonia would be in keeping with this.

Dr Garalevicience also gave evidence the aspiration started at lunchtime. Ms Debbage agreed.

The coroner summarised Ms Debbage’s evidence, that it could have been that Peter had residue which had passed from his larynx to the vocal chords, and being sick suggested it was unresolved. She also suggested that Peter’s swallow could have changed and that can happen very quickly.

Either way I find Peter was at risk of aspiration, as set out clearly and plainly in his SALT care plan, which was why it was so important all the steps set out by Ms Debbage should be followed to the letter.

I am satisfied the evidence is that the episode of aspiariton which led to Mr Seaby’s death started at lunchtime.

Peter was not supervised in accordance with the care plan, he was not supervised by a person sat next to him. Had he been, I am satisfied on the balance of probabilities, the slice of carrot would have been seen, and he would have been prevented from eating it.

In addressing whether Peter’s coughing related to being given the carrot, and whether that coughing was the course of the aspiration, the coroner said this was problematic as she’d taken on board Ms Debbage’s evidence that his swallow could deteriorate very rapidly.

There is no evidence that the aspiration was probably as a result of coughing, which was probably as a result of eating the carrot. However, I do not accept this was merely speculative, as submitted by the care home, nor that the carrot is a red herring.

She continued:

It was at lunchtime I found Peter swallowed a slice of carrot. Had his food being adequately prepared, and had he been adequately supervised, he would not have been given and swallowed a piece of carrot.

The evidence of Ms Debbage is coughing can cause aspiration. Dr Garalevicience said coughing can cause aspiration. Peter started coughing that lunchtime.

The coroner said she had the evidence of Dr Lonsdale, Ms Debbage and Dr Garalevicience to consider with regards to coughing.

I do find inadequate preparation of Mr Seaby’s food on 21 May, and his being inadequately supervised, possibly contributed to his death.

She said had the GP been given the full record and evidence of events of that day, it was likely that there would have been a different outcome to that appointment, and Peter was likely to have been admitted to hospital. However she had no evidence before her that had Peter been taken earlier to hospital, that the outcome would have been different. She said she made no finding in that regard, and it did not break the chain of causation.

She continued:

On behalf of Peter’s family I’m invited to add a rider of neglect to this narrative, on behalf of the care home this is refuted. I have carefully considered evidence and both sets of submissions. There has to be a gross failure to provide adequate nourishment, or to provide or procure medical attention for Peter.

She said that it could not be disputed that Peter was in a dependent position, physically and mentally. He could not provide for himself. However, she found that he was provided with adequate nourishment, and she could not find that there was a gross failure to provide basic medical attention as Peter was taken to the GP, and 111 were called. On that basis she would not add the rider of neglect to her narrative conclusion.

The final conclusion in Peter’s second Article 2 inquest was:

Peter Seaby died of aspiration pneumonia. Inadequate preparation of his lunchtime meal and inadequate supervision at his lunchtime meal possibly contributed to his death.

The coroner is making a prevention of future deaths report to the Priory Group in respect of three aspects, five years after Peter’s death. I’ll write a post on that another time.

With thanks, as always, to my crowdfunders, without whom this reporting wouldn’t be possible, and to Mick and Karen Seaby,