I’m reporting the coroner’s summing up and conclusion in stages. The first post is here. This post will cover what the coroner concluded about the events of Sally’s death, the post mortem findings and the cause of death.

The coroner said that on Thursday 26 October 2017 Sally had enjoyed what appeared to be a fairly typical day, her Key Worker Susan Casey told the inquest Sally had been fine that day, been shopping which she enjoyed, no problems with food that day.

Sally usually went to bed at 10pm. Around 7pm she appeared sleepy and tired… asked if she wanted to go to bed, she said she didn’t. Ms Casey made her a hot chocolate which she didn’t drink quickly like she usually did. There was a bug going around which other residents and staff at the home had caught. Sally also appeared wobbly on her feet that evening.

Susan Casey said that her colleague Victoria Howe had just gone home, and so she asked her to come back and see what she thought. Sally was hot and clammy to touch, Vicky thought she had got the bug, and she then went home.

Pausing there, Victoria Howe gave evidence about that evening as well. Susan Casey told her Sally didn’t appear well, didn’t seem right, was hot and clammy to touch. Ms Howe said she agreed with that, there was also a sickness and diarrhoea bug in the service and she thought she might be coming down with that. They didn’t have any conversation about consulting the bowel charts for Sally.

In answer to a question from Mr Breakell for Dimensions, Ms Casey said she was hot and clammy, I did ask Victoria Howe to come back, and Ms Howe said in her evidence in answer to questions from Mr Breakell, I spoke with Ms Casey, we didn’t discuss calling a GP. Although Sally was clammy to the touch, she was full of energy and mobile, and physically seemed herself, by the time I left I didn’t have major concerns about her. She said if Sally hadn’t been mobile, had stopped taking fluids or seemed out of character she probably would have sought medical assistance.

Ms Casey recalled Sally falling asleep on the sofa, that was unusual for her… she woke her up between half 10 and quarter to 11 asked if she wanted a drink before going to bed, and Sally had another hot chocolate. She said she remained quite sleepy, usually she’d sing before going to bed, in this case she stood up and sat straight back down…. She appeared wobbly and drunk, I didn’t think about calling a doctor she said.

Sally remained on the sofa, once she realised she was quite settled about 3am she went to bed upstairs. Ms Casey said that throughout the night Sally’s breathing was quite heavy, she didn’t know if it was normal for her, when she next checked at 5am Sally was breathing heavily … Sally remained asleep on the sofa.

Sonia Parchment, another Support Worker, came in at around 07:50 that morning, they both walked into the lounge. She saw Sally sitting up on the sofa, Sonia said Sally looked unwell and then she thought Sally was deceased. Susan Casey said:

When I walked into the lounge I didn’t see anything different to the last time I checked … I guess I’d last seen her 20mins before … I didn’t tell Sonia Sally had been awake all night … when Sonia said she thought Sally had died I was shocked.

Susan Casey confirmed in her evidence she didn’t recall Sally’s sister Julie Bennett raising concerns about recent change in Sally’s behaviour, or indeed anything else. She said she herself had never been trained in sepsis and she wouldn’t be able to recognise sepsis. She said she hadn’t sought medical advice or called 111 because Sally hadn’t appeared too poorly, she said she had no idea that evening that Sally was seriously ill.

Sonia Parchment hadn’t worked at The Dock before 27 October 2017, but previously worked with Sally at Stourbridge Road.

She confirmed on arriving at The Dock … she saw Susan Casey in the hallway by the front door, she waved, she didn’t notice me, I got to the front door, waved again and again she didn’t notice, I knocked… she let me in … she was agitated and speaking quickly… I saw Sally sitting upright, her jaw had dropped, could see clearly she was unwell and said to Sue Casey I thought she’d passed away.

Sue said it had only just happened … I could see clearly she had gone, because Sue said it only just happened, we got Sally onto the floor, wiped her mouth and started CPR.

She said Sally was still warm at that stage, she shouted to Sue Casey to call 999 and she commenced CPR.

The coroner said that the paramedic records show a call went out at 07:57 that morning and paramedics arrived within 7 minutes. Their documentation also recorded Sally was last seen alive at 07:50, then discovered unresponsive 8 minutes later.

That last piece of evidence is directly at odds with Susan Casey’s own evidence, she made no mention of seeing Sally alive at 07:50, doesn’t appear supported by Sonia Parchment’s evidence either.

I prefer Ms Casey’s evidence she last actively checked on Sally at 5am and Sally appeared to be breathing heavily.

I find it more likely than not she did not make such a check at 07:50 and it is more likely Sally died at some point between 05:00 and 07:50.

Despite attempts to provide advanced life support, paramedics were unable to revive Sally and she was formally declared as life extinct at 08:32 that morning.

A post-mortem was conducted by Consultant Histopathologist Dr Terry Jones. That took place on 31 October of 2017.

Dr Jones significant findings were:

Firstly, Sally’s stomach was dilated and contained foul smelling semi-solid yellow material

Secondly, her large bowel was grossly distended from the rectum to the caecum

Thirdly, was gross faecal impaction in the rectum extending into the sigmoid colon, and

Fourthly, the transverse colon, in addition to dilation, showed early signs of necrosis.

Dr Jones commented the appearance was of gross faecal impaction, causing large bowel obstruction and necrosis.

Dr Jones gave the medical cause of death, which I accept, as 1a large bowel obstruction, due to 1b faecal impaction.

[The next post will discuss the coroner’s conclusion in regards to what happened after Sally’s death – you can read it here].