Peter Seaby’s 2nd inquest – Priory Group failing to prevent future deaths

This is my final blog post relating to Peter’s second inquest, you can find all the earlier ones here and here and here and here and here and here and the conclusion is summarised here. At the end of an inquest it’s not unusual for a coroner to hear evidence from any interested person’s who has clearly failed in some way, to understand whether the failings identified during the inquest process remain risks to others. This is covered under Regulation 28, Prevention of Future Deaths. Theoretically PFDs could lead to a tangible benefit to others, nearly all the bereaved families I’ve ever spoken to are driven in part by a desire to prevent any other family experiencing what they have, and PFDs could play a key role in that. I say could because the reality is far more nuanced, but that’s something I’ve written about before and will return to again I feel sure.

Peter Seaby died in May 2018, 4 years and 9 months ago. There was a police investigation into his death. There was a LEDER report, which the family told the court in their evidence was littered with inaccuracies (not uncommon criticism of LEDER reports I might add). In August 2021 Peter’s first inquest took place, in front of a jury in Norfolk. I live-tweeted it and you can still find the evidence discussed in court here. Peter’s family and legal team issued a judicial review challenge after the first inquest, arguing that the coroner had erred in law, and instructed the jury incorrectly. They were successful in their challenge, and Peter’s second inquest took place last week, Article 2 without a jury this time, 5 days of evidence.

Yet the coroner felt the need to issue a prevention of future death report on three counts. People still at risk. Almost 5 years later, after all that performative scrutiny above. It’s almost as though The Priory Group view preventable and premature deaths as collateral in their business endeavours. I am struggling to find any other explanation.

They sent Sarah Mann, Director of Quality in Priory Adult Care along to give evidence to the coroner about the changes made since Peter’s death, and to try to argue that no further risks were outstanding.

Her biography on their website states:

Since joining Priory [in 2015], Sarah has held various roles from Investigations Officer to Associate Director of Nursing for Adult Care before moving to Associate Director of Quality in 2018 and Director of Quality in November 2021.

She answered numerous questions from the coroner stating how they had new systems now, new electronic recording systems being rolled out, new processes, policies and standard operating procedures. She was at pains to point out that these weren’t changes as a result of Peter’s death, but changes due to the passage of time. I’m not going to report what she claimed here, instead I’ll share some extracts from her questioning by the family’s counsel Mr Cridland.

Mr Cridland, for Peter’s family, wanted to understand the roles she’d held since Peter’s death:

SC: Yes thank you, now Ms Mann you tell us in your witness statement 21 Aug 2021 that at that stage you were Priory Adult Care Division Associate Director of Quality, and now you tell us you’re Divisional Director of Quality with Priory Care…. Same area but a promotion?

SM: Originally I was Associate Director of Quality for Older People Nursing Services, with my nursing background, now I am Director of Quality.

SC: Being Director of Quality, what are you actually responsible for?

SM: Improving systems and processes for resident safety, regulatory compliance and ensuring the best quality of life for all our residents, and staff.

SC: Was Oaks and Woodcroft part of The Priory when Mr Seaby was there?

SM: Yes

SC: Do you know when Oaks and Woodcroft became part of Priory Group?

SM: I’m afraid I don’t know

Sarah Mann confirmed that she’d taken up her role with responsibility for adult care after Mr Seaby had died, so Mr Cridland sought to understand her responsibilities further:

SC: So, post the event, we’re not talking when Peter was resident, but do you regard yourself post the event, having put in those three witness statements, as having a responsibility within Priory Group for his case and what happened?

SM: Of course, absolutely.

SC: You do. Can you help me with what specific investigation the Priory Group has undertaken in relation to Peter’s case, and what occurred?

SM: There hasn’t been an investigation into Peter’s case.

Before we continue with Mr Cridland’s interrogation of the smoke and mirrors surrounding the Priory Group response to Peter’s death, can I just ask how this is humanly possible? Peter was removed from the care of his family, his beloved sister who he shared a bedroom with (his choice, they lived in a two bedroom home but Peter preferred to be near Karen) and shared his life happily with for so many years.

Peter was taken, against his families will and they believe against Peter’s will, into the care of the state by Marcia Solloway-Brown, a social worker whose evidence to the court was she’d arranged a respite placement and funding, and had staff on standby to transport Peter, before her unannounced visit, not that it was a foregone conclusion of course.

We heard how Peter didn’t sleep well at Oaks and Woodcroft, often spending all night walking around, his family believe looking for Karen. Utterly heart breaking. 63 years living with his family, and after less than 6 months in the care of the state, and the Priory Group, Peter was dead, but they didn’t bother to do any internal investigation. Nothing.

Mr Cridland continues trying to understand what actions the Director of Quality has taken:

SC: Obviously when you put in your witness statement 21 August 2021, at that stage you’re apprised of Peter’s case. Was it about then or before then?

SM: It was about then I was first aware

SC: You’re asked for witness statement for the purpose of an inquest that year. Once you’re apprised of his case, what did you do personally to understand potentially what had happened in relation to Peter and his care?

SM: I worked with my team who were in place at the time, the wider team at Priory, to try to understand the events of what happened.

SC: How? I’m trying to understand specifics. I appreciate some work was delegated, what was done once you’re apprised of this by you and your team? To get to the bottom of what happened?

SM: We reviewed the case to make sure we had everything in place at Oaks and Woodcroft, to make sure we had everything in place.

OK, maybe it’s not as bad as it first seems. There’s a review of Peter’s case, not a full internal investigation, but a review. So what did that involve?

SC: Did your reviewing of the case go to looking through Peter’s care records?

SM: Not personally, I’ve looked at Peter’s care records but I haven’t gone through them in great detail.

SC: You told us you felt responsibility in Priory Group for his case, and your role extends to regulatory compliance and resident’s safety. Did you not want to yourself look at his records to see what if any light they might have cast on what happened and the nature of care he was being provided with?

SM: I think with hindsight I should have but I didn’t at the time.

Mr Cridland asked why she didn’t learn about the concerns at the first inquest.

SM: I didn’t attend the last inquest I’m afraid.

SC: And you weren’t briefed of any issues flagged up and any incidents given?

SM: As far as I was aware the last inquest was closed and there was nothing for us to act on.

SC: So, the Priory position was after the last inquest, they regarded the matter was closed, and nothing from that inquest raised concerns in relation to Mr Seaby’s case?

At this point the coroner intervened, to check whether Ms Mann thought it was fair comment.

SM: Sorry I can’t answer that

SC: We’ll come back. It’s fair comment isn’t it a review of Mr Seaby’s care records suggest on occasions his SALT plan wasn’t being followed?

SM: Yes

SC: His food was not prepared in accordance with his SALT care plan

SM: Yes

SC: And not being followed in so far as he wasn’t receiving the 1-1 supervision at mealtimes he should be?

SM: Yes

SC: It’s also fair comment isn’t it that a review of his records suggest a potentially serious choking incident on 15 April?

SM: Yes

SC: And also fair comment isn’t it, if one looks at care records for 15 April and compares contents of care records with the content of the incident report, and Kelly Mann, the social worker’s account and witness statement of what she’s told by Ms Cuzner, there’s a significant discrepancy between care records, and accounts from the incident form?

?: I’m sorry I didn’t hear Ms Mann’s evidence

At this point I’m not sure from my notes who said that, I suspect the coroner, but it could have been Ms Sutton either, counsel for the Priory Group. I’m also not sure what the response was, apologies. Back to Mr Cridland:

SC: Have you looked yourself at the care records from the 15 April?

SM: No I have not.

SC: Have you looked yourself at the incident report form from 15 April?

SM: No I have not.

SC: So the first you understood the incident hadn’t been investigated by the manager, was when that became an issue within this inquest?

SM: Yes

SC: So although you felt a responsibility for Peter post the event, and although your role extends to regulatory compliance and patient safety, am I right you didn’t and haven’t prior to now asked to see any incident reports generated during Peter’s time at Oaks and Woodcroft?

SM: I asked to look at incident reports but there weren’t any available apart from the one that was not completed.

Hang on, so what’s happening, if the Director of Quality, or anyone in a quality team asks to see incident reports and they’re told they’re not available, apart from one incomplete one, would that not be concerning? Sort of suggests that she’d been proactive…. but hang on… Mr Cridland knows not to take anything at face value:

SC: When did you first see the one from 15 April?

SM: On Monday

SC: When did you first ask to see the report?

SM: On Monday

SC: You’ve put in a couple of witness statements, your role extends to regulatory compliance, you’re in that role in 2021, you confirmed you felt a responsibility for him post the events, but putting all that together you didn’t think before the start of this inquest, given you feel responsibility for him and your role extends to regulatory compliance, you should review yourself any incident report forms generated during Peter’s time at the home?

SM: I didn’t review them no

SC: Did anyone else have that task directed to them?

SM: My understanding is our Director of Risk and xxx [didn’t catch] have reviewed the records and undertaken that piece of work.

I’m not sure this needs much analysis so I’ll just continue with Mr Cridland’s questioning:

SC: Fair comment isn’t it that it’s concerning a choking incident on 15 April, that the manager hasn’t completed their review?

SM: Yes it is concerning

SC: Because the purpose of that review is to identify any lessons that should be learnt?

SM: Yes it is concerning and yes that is the purpose

SC: As part and parcel of your own involvement in this case, prior to the start of this inquest, you hadn’t yourself reviewed any incident review forms of Peter’s time at the home, and prior to this inquest you hadn’t reviewed his care records?

SM: Not in full

SC: For the 21st May?

SM: Yes

SC: But not the 15 April?

SM: No

SC: And prior to the start of this inquest you yourself hadn’t reviewed any of the witness statements?

SM: No I had not

SC: So you weren’t aware of this potential discrepancy between what Ms Cuzner reported in the incident report form and told Ms Mann at Norfolk County Council, and what was recorded in the care records from 15 April?

SM: No I was not

SC: It’s really concerning isn’t it there was that discrepancy?

SM: Yes of course

SC: Can you help me with what will happen at the Priory after this inquest to investigate that matter [I think he said]?

SM: We will undertake an investigation to understand what happened, of course.

SC: You’ve reviewed records, on their face they raise concern about whether his SALT plan was followed that day?

SM: Yes

SC: In relation to his food and 1-1 supervision?

SM: Yes

SC: When did you become aware a review of his records for 21 May raised those two concerns?

SM: I don’t recall

SC: What has been done specifically by Priory Group to review those matters?

SM: Nothing to date

SC: Why not?

SM: I cant help with regards to the lack of investigation into this case, I can help you with what would happen now….

SC: Ms Cuzner suggested it was because the medical cause of death was reported as natural causes

SM: It would not be case now, an unexpected death in one of our services would be reported up in 2hrs and we wouldn’t know whether it was natural causes or not

SC: It wasn’t a good reason at the time was it?

SM: No

SC: Will there be an investigation by Priory Group after this inquest?

[Unfortunately I can’t tell from my note exactly what she said but it was affirmative]

Mr Cridland then went on to discuss the new Standard Operating Procedure that had been written to ensure that carers who knew the resident took them to the doctors, and that they took the notes with them. Even then Mr Cridland pointed out a concern the family had with it as written:

SC: Concern here is what needed to happen in Peter’s case is as we discussed, either records should have been photocopied and gone with Ms Horne, or a note setting out what had gone on.

SM: Yes

SC: I don’t see that here. You might think is obvious, is any training given to staff that attendance for acute reason should be carer with knowledge and experience of what’s occurred, or alternatively need to photocopy relevant records if there are any and go with records?

SM: Agreed, it doesn’t spell that out, would be expectation is someone who knows the service user who goes…. In terms of that being specifically written it isn’t.

Ms Sutton confirmed later that she had the pro forma for this policy and would be able to edit, and the coroner confirmed the next day that it had been edited, but part of the problem is that things aren’t spelt out clearly enough in the first place.

Mr Cridland’s questions followed those of the coroner, where Ms Mann had been at pains to point out that the staffing ratios wouldn’t allow a repeat of this situation, and yet all was not that straight forward as it turned out they hadn’t changed since Peter’s time.

Mr Cridland worked through the list of staff that the police had ascertained were working on the 21 May with Ms Mann, and then concluded:

SC: So other than Ms Peloe who didn’t suggest she was providing the 1-1 he requires, there’s no one available to do it. Having worked through it what I’d appreciate from you, and the family would appreciate, is how that state of affairs couldn’t arise again at the Oaks and Woodcroft?

SM: We have staffing ratios reviewed on a regular basis according to need. Staff in line with local authority funding arrangements, 1 member staff to 3 residents during day, 1 to 6 at night, with 1 in each bungalow and additional member at night in event of anything happening on rota every night

During the day 3 members of staff per bungalow and any 1-1 support in addition to that. In case there were two people on 1-1 there would be 5 members of staff during the day.

SC: So Ms Maunder, Ms Peloe and Ms Cator, Ms Cator we know is in hospital so they’re down to two. Ms Maunder is providing 1-1 for 12 hours, and Ms Peloe is looking after the other 5 residents?

SM: Yes

SC: That would be avoided now because they’d be additional members of staff for 1-1?

Except they were funded to provide 4 hours of 1-1 support to Peter daily for his eating and drinking, and staffed accordingly.

SM: Yes, and where they fall below expected to report up

SC: Is there a situation where if need another pair of hands someone can be supplied at short notice?

SM: Can borrow from other homes if needs be and its safe to do so, or we have agencies we can rely upon, or the Manager or Deputy can step onto the floor

SC: Is that a change from 2018 or would you expect it to be the case in 2018?

SM: I would have expected it to be the same in 2018

C: you’d expect those numbers?

SM: I’d expected them to cover, wouldn’t expect them to leave home with unsafe numbers, escalate, request for support or agency

C: Is 1-1 staffing new since 2018?

SM: No, I don’t think so

C: Ooh that’s how I’d understood it

SM: No, 1-1 should have been extra in 2018

I think that’s how everyone in court had understood, because that was how it was presented. So what did the coroner decide? This is what she said when it came to her duty to issue a report to prevent future deaths.

There have been many concerns raised at this inquest.

First of all I would say I do not propose making any Prevention of Future Deaths reports against Norfolk County Council, evidence has been heard in that respect, I am of the view my duty has fallen away.

I have heard evidence from Ms Mann with regard to action taken since Mr Seaby’s death, not necessarily as a result of his death, but since his death, to put in place steps to prevent future deaths.

Many steps have been taken.

Ms Mann was quick to take action with regard to the SOP in place in respect of taking a resident to see the GP so that the GP in future occasions has as much information as possible. In that respect I do not propose to make any report to prevent future deaths.

However, I am concerned some 5 years after Mr Seaby’s death I have heard evidence from a witness who is still at the care home that the informal approach to supervision and preparing work rotas is stated to work, when it clearly doesn’t.

There was reference more than once that an informal approach is the way to provide care in the care home, and whilst that is commendable in providing a caring environment, this must be balanced with the need for structure and rules and protocols which must be followed by all those involved in the care of vulnerable residents.

Those requirements are there for a purpose and an informal approach has no place in a care home.

I am also concerned with regard to staffing levels provided. I was not clear and satisfied from the evidence heard from Ms Mann are now sufficient staffing levels in place to provide for all residents who require 1-1 supervision, or when other residents are taken out or doing activities.

Further I am concerned there has till been no internal investigation as a result of Mr Seaby’s death.

There has already been one inquest, we now find ourselves at the second inquest.

Ms Mann gave evidence she will carry out an internal investigation following this inquest however that was only following the question being put to her.

Ms Mann was not present every day to hear concerns raised, or what was being said by witnesses, some of whom are still employed by the care home.

She did appear to be surprised by some of the evidence put to her.

I do think an internal investigation in a case such as this is paramount to ensure all possible learning from Mr Seaby’s death can be gained, and to ensure that full steps are taken in respect of the concerns that have been raised throughout the evidence that has been given.

So I will be making a Prevention of Future Deaths report in respect of those three matters.

5 years after Peter’s death the coroner’s PFD report will focus on three areas: supervision of responsibilities and the ‘informal’ approach to care; staffing levels, particularly 1-1, and the lack of investigation by the Priory Group into Peter’s death (and perhaps also within that their lack of investigation into concerns and serious incidents during his time at The Priory).

Before I finish I want to say something about neglect because I’ve had a few private conversations with people and I think it’s worth saying more here too. The dictionary definition of neglect is to ‘fail to care for properly’, unfortunately the legal definition is much more stringent. I’ve written a fair bit about this, because its probably the aspect that confuses and troubles me the most. If you’d like to read my attempts to explain why neglect is so evasive in a coroners court when looking at the deaths of learning disabled and autistic people, then this post might help, from a few years ago, When is neglect not neglect?

So that’s it. Almost five years after Peter died, after a shed load of performative scrutiny, a police investigation, a wait, a LEDER report, a wait, a first inquest, a judicial review challenge, another wait, a second inquest, finally Peter’s family feel that they have secured something close to justice for Peter and can start to think of him with their many, many fond memories, and not just the actions that led to his death.

In the first inquest the coroner instructed the jury (incorrectly) that they had to find Peter died as a result of natural causes, or that they could write a short uncritical narrative, she also excluded many of the areas of concern that we’ve heard about this inquest from them. Telling them they were not allowed be critical or offer an opinion. She also said she had no ongoing concerns and was satisfied that there was no reason for one.

Yet here we are, a further 18months later, with the Senior Coroner for Norfolk issuing a damning conclusion, and a Prevention of Future Deaths report on three matters where she has ongoing concerns relating to the Priory Group.

I spoke to Peter’s sister, Karen, yesterday. She said she felt this coroner was very thorough, and that she was pleased that she’d addressed all that she did. I’ll leave the final word to her brother, Mick, who read this statement out after this second inquest concluded on friday:

“We were really disappointed with the conclusion of the last inquest. We felt like this didn’t answer all our questions and we didn’t get the conclusion that we wanted or felt like Peter deserved. Although the idea of a second inquest was daunting, we felt like we owed it to Peter to have a second inquest, to get justice for him. We loved our brother Peter dearly, he was a lovely, fun, cheeky chap and Karen spent her whole life caring for him. We hope that lessons are learnt by both Norfolk County Council and the Priory Group to avoid anything like this from happening to another vulnerable individual like Peter.”


My coverage of Peter’s first inquest is here and a blog post introducing Peter is here, Peter Seaby hated carrots.

All of my reporting is thanks to those people who generously crowdfund my work. One off donations can be made here, anything, every penny, is gratefully received.

A review of my last three years reporting, the work, and the finances, is available here.

Just to give a heads up, I found reporting Peter’s second inquest incredibly difficult, I find reporting every inquest difficult, but emotionally it was challenging and now Twitter is no longer stable (or a platform where I want to spend much time) I’ve resorted to listening in court and reporting after. This is much more work, but important to provide the scrutiny, I think? I’d welcome your thoughts on that, and these blog posts, as a method of sharing inquests. I’m seriously considering the future of my work in this space and it would help to know if people are interested/ reading/ sharing. Thank you.

4 comments on “Peter Seaby’s 2nd inquest – Priory Group failing to prevent future deaths”

Sue Walters says:

As I have a learning disabled son, your reports are of great interest to me and have helped to give me some understanding of others’ ( users of and their families, observers of, and workers in social care and health care) experiences and thoughts ,as well as the findings of coroners and the actions of public bodies and Care Providers.
Regarding Record keeping: my son has never been in residential care but has had many years in supported living which as you know is largely unregulated. While he was ‘temporarily’ staying with me during what turned out to be a prolonged episode of poor health, I had reason to request sight of the Daily Care Notes covering a couple of years. One reason was to have correct information to give to his new GP and various other professionals. It took me two years to get them.This was in spite of the Provider being reminded by the Local Authority that my son consented and that there was no reason why I should not have them. When I did get them,they often noted information available elsewhere, but omitted important information.They included reference to other documents to be completed in the event of medical concerns or behavioural challenges. When I requested sight of those, (preparing myself for another two year wait), I was told they ‘couldn’t be found’ which seems to be a common theme in your reports.It therefore proved impossible to discover how concerns flagged by support workers had been actioned by more senior staff (or not). So I am completely unsurprised by the impression/evidence of record keeping apparently frequently provided ( or not provided )to Coroners. No one seems to take the necessity and reasons for record keeping seriously or to support and supervise staff who should be completing it. I believe the more people know about the realities of social care,and the stresses which underfunding places on all concerned with it, particularly in these times of near collapse of public services, the better. So yes, your work definately is valuable – but it shouldn’t be left to the willingness & effort of one person to undertake it. Thank you for doing it – but I would understand if you no longer felt able.

LizPiercy says:

I am trying very hard to comprehend the indifference of the Priory Care Group. What can be more serious than a resident’s death? At what point are they bothered enough to review Peter’s care, to worry that they did not provide the 1:1 care commissioned, to attend an inquest?
It seems this organisation doesn’t really care ( though there are many people carrying out the actual care who do). They do not care about understaffing, poor training or about avoidable deaths. There are no consequences for them. No-one fines them or stops using them or closes their business. They can do what they like and PR their way through the occasional bit of bad publicity. Sarah Mann came to Peter’s inquest when she was required to but think how much she could have learned if she had attended the whole inquest.
There needs to be better control of the private sector. If we can’t make them, as organisations, care maybe we can make them comply.

Thank you George for your huge amount of work on this. I find the blog posts easier to follow and your comments and links helpful. I agree that twitter has lost its usefulness now. But we shout and shout and little changes. We have a government who doesn’t care about any of its citizens.
I would understand if you stopped for now George – though totally believe you could be the next Michael Buchanan:)

Sarah Sea says:

Thank you George for all your tireless hard work covering this and other cases, and for shining a light on how disabled people with high care needs are treated by the social care system in this country. I became familiar with your work through Twitter & think what you’ve been posting there is so valuable, but completely understand that after recent developments it’s becoming a space where it’s much more difficult to do that effectively – but wherever and however you’re sharing your work, it’s still incredibly valuable and needs to be heard. If blog posts are a better way to achieve that, then so be it I guess!

Anna Rose says:

I am at the beginning of all this for my beloved son who died unnecessarily in a nursing home. It has been a painful privilege to slowly discover this ‘other world’ of neglect after a lifetime of fighting inadequacies in our so called ‘care’ system. I don’t want to believe my eyes. I read Sara Ryan’s brilliant account of her terrible experience thinking, well that was a long time ago and there were serious actions taken arising from her and George’s and of course others’ persistence – so surely all should now be well and my poor son was an exception.

If it weren’t so serious I’d say ha bloody ha. But it is and we seem willing as a country to sacrifice an unimaginable number of vulnerable people not only to sub-standard care (along with unacceptable conditions for their carers) but an unimaginable number of premature and awful deaths. Each a tragedy. Each a person. Each with a family and friends.

Accountability ….. where do we go with that?

So thank you George. You’ve ploughed a unique path, enduring extreme concentration and exhaustion to bring to light what is going on for this ‘silent’ group. Utterly understandable you’re getting weary. If you have to stop – or pause – it’s more than understandable. But I can’t help hoping you don’t. This is part of a huge thing that so needs more exposure. Sounds as though there’s a need for more than one of you. But to return to silence is unthinkable. What can we do to keep what you do going with less toll on you or anyone else who takes up the baton?

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