On the final day of Sally’s inquest the coroner opened with Julie, Sally’s sister. First she read a pen portrait of who Sally was and what she meant to her family, you can read it here.

Next the coroner said he’d read parts of Julie’s statement onto the record. He told the court that this was the statement of Julie Bennett, and she says this:

Sally was an amazing person and a wonderful sister, daughter, and auntie. Sally really was adored in our family. She left home when she was really little but she used to come back every single week on Sunday. Sunday was always ‘Sally’s day’ and the whole family would focus on making sure she had a great day.

This remained the same throughout Sally’s life. We would see her regularly, every week.

She always came and joined in family celebrations like birthdays, Christmas, and on Easter. Even when our mum got older and had to go into a care home, Sally still visited her. After our dad died, Sally used to say goodnight to him every night before going to bed, looking out of her window.

She was a happy, much loved, and integral member of our family. She will be sorely missed by everyone that knew her, but by us the most.

Sally lived in four placements before moving to The Dock. Three of the placements she lived in were run by Dimensions. One of her carers at The Dock, Sue Casey, had looked after her for a very long time, I think since she was in Sunfields, a placement she lived in when she was very little. And so although she moved around a little bit, there were some carers who she knew very well.

Before moving to The Dock, Sally lived at a placement on Baveney Road in Worcester, and then a place on Stourbridge Road in Worcester. Baveney Road was a wonderful place for Sally. Sally could walk all around Worcester with her carers and would often come to see me and other family members. We would also go to visit her in Baveney Road. She seemed really happy there.

She used to do all sorts of activities, church on a Sunday, going on holidays, pottery, the beauty salon and horse riding. I think Sally was truly happy at Baveney Road, and I personally think that her active life whilst living there probably helped manage her constipation better. It is common knowledge that regular exercise helps with constipation.

I remember at some point before Sally moved to The Dock, I can’t quite remember when, Sally came to my flower shop one day and was really upset and angry. Something flipped in her mood and she knocked into me, sending me flying across the shop.

She kept talking about ‘the book’, a punishment from her time at Lea Hospital in Bromsgrove, a unit where she had been cared for when she was younger. I remember being shocked at how upset Sally had gotten. We spoke with her psychiatrist and I think her medication was changed at that point, which I think helped a bit.

We weren’t happy with the placement at Stourbridge Road and so I had been calling Dimensions trying to get Sally moved to a placement very close to my parents’ house in Malvern Road in Worcester. We tried several times, but it had no vacancies.

It was suggested that Sally should move to The Dock, a much more modern placement that was more appropriate for Sally’s needs. So although it was out of Worcester, we were happy. There was a nice large living room with patio doors out into a garden, and we thought that the place might become a nice home for Sally, like Baveney Road was.

Sally moved to The Dock in May 2016. Unfortunately life did not really improve for Sally. She remained more sedentary, didn’t go back to going to church, going on her long walks, or going on holiday.

Sally did get taken out once a week to go to ‘Snoozeland’ which had a sensory room for Sally to sit in, but other than that I was not aware of her doing anything else.

I remember she stopped going to church after moving to The Dock. It was a real shame as she used to really enjoy seeing the vicar and having a glass of squash, and she used to sing during services.

I’m not sure why this happened, but I remember once being told that they did not always have enough staff to make sure there were people with Sally and also with the other two residents.

Sally continued coming to see the family every week. We went to The Dock sometimes, but it was further away. I was diagnosed with cancer in 2015, and so the visits out to Sally’s home became a bit less regular.

I remember it really hit home that Sally’s behaviour had changed when on her birthday, on 25 June 2017, we went to visit her at The Dock. I remember we saw a new car outside, and one of the carers said: Do you like Sally’s new car?

We were told that she had bought it using her Disability Living Allowance. I remember asking why Sally needed a car, as she loved walking everywhere. The carer said Sally won’t walk anywhere.

I remember being surprised by this as she used to be so active. I thought that maybe it was just Sally getting a bit older and didn’t necessarily think there was something wrong with her medically speaking.

I now believe that she may well have been in pain or feeling unwell, and that more should have been done to identify the cause of the change in her behaviour.

I remember around September 2017 I started noticing a marked change in Sally’s behaviour and appearance. She had been coming to see me at the flower shop and was being very quiet and disengaged. I remember always asking her carers what was wrong with her. They often just said something like ‘she’s just tired’. But she was a long way from the happy, bubbly Sally that I knew.

I remember also noticing that her stomach was getting bigger. I assumed she was gaining weight and remember commenting on it to her carers. The carers would just say that they were monitoring Sally’s weight. I kept mentioning it, but the carers always just said that they were monitoring it.

I would always buy Sally loose fitting clothes, so she was comfy. When she was at Baveney Road I would buy her size 16 clothes. By this time at The Dock, she was wearing size 18 or 20. Sally ate a lot. You really had to make sure you managed what she ate, if you had a plate of biscuits in front of her, they would be gone in minutes. I remember being worried that The Dock was not managing her diet very well. I was always told that she was eating fine.

The coroner then said, moving on to the date of Sally’s death, Ms Bennett continues:

When I arrived at The Dock that day, there were quite a few people there. Julie Campbell, the area manager, was there with Sue Casey, Sonia Parchment, another carer and two paramedics. An ambulance was parked outside.

Sue greeted us and led us into the dining room, next to the living room in which I later learned was Sally’s body. We were told that there were paramedics with her. The paramedics came into the dining room and said that there was nothing more that they could do.

After a short while, I went into the living room. Sally was lying on the floor, next to the sofa in front of the doorway.

The first thing I noticed immediately was that her stomach was absolutely huge, it was awful. Her tummy was so distended, it looked like she was about to give birth.

Next to her was a pool of vomit and there were tubes next to her that I presume the paramedics has used. It is hard to describe how difficult it was to see Sally lying there, like that.

Sally was a wonderful woman, she was a much loved daughter, auntie and sister, it’s devastating hat she was taken from us because of constipation. I hope through this inquest changes can be made so no one like Sally dies of such a simple problem again.