Preventing Future Deaths: Lugh Baker and David Hemmings

What is a Prevention of Future Deaths report?

Coroners have a duty to take action, when they become aware of circumstances during the course of their investigation that they consider creates a risk of deaths occurring. The duty is quite broad and is not restricted to matters revealed in evidence at the inquest.

Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.

MOJ Website

Coroner’s discharge this duty, through issuing a Prevention of Future Deaths (PFD) report, and reporting the matter to the person that the coroner believes has the power to take action.

The Chief Coroner, in guidance he has issued, states:

PFDs are vitally important if society is to learn from deaths.

He also states:

 In considering whether they are under a duty to make a PFD report, coroners should focus on the current position. This will normally be the position at the end of the inquest unless, unusually, consideration is being given to making a PFD report before the resumed inquest. Coroners should consider evidence and information about relevant changes made since the death or plans to implement such changes. If a potential PFD recipient has already implemented appropriate action to address the risk of future fatalities, the coroner may not need to need to make a report to that body. Whether a coroner needs to do so or not is a judicial decision for the coroner to make on a case by case basis taking into consideration all the circumstances. However, a report to a relevant national organisation to highlight the issues more widely may still be appropriate provided the evidence suggests that the risk of future fatalities may arise nationally and the coroner believes that national action should be taken.

PFD reports are usually issued at the end of an inquest, which is why represented parties will often go to such lengths to explain in court the myriad of changes they have made since someone died, to avoid being given one. My concern is that coronial processes take so long in some parts of the country, that people are actively left at risk for years in the interim.

I don’t wholly agree with the Chief Coroner’s assertion that PFDs are vitally important for society to learn from deaths. PFDs certainly have the potential to be a vitally important tool in society learning from deaths, 100% agree with that. But, given the current delays in coronial processes I think it’s ambitious to consider that’s the role they’re taking. Unless more coroners start issuing PFDs earlier in the inquest process that is.

Coroners are permitted to make a report before an inquest has concluded, if they believe urgent action needs to be taken, such as a recent one issued by Emma Brown, the Area Coroner for Birmingham and Solihull to St Andrews Healthcare (those who run the warehouse in Northampton) who is conducting an investigation into the death of Steven Sanders. Steven’s inquest is due to be heard in front of a jury, starting next week. He was detained under Section 3 of the Mental Health Act on Hawksley Medium secure ward of St Andrew’s Healthcare in Birmingham. Steven’s death was initially thought to be natural causes, due to coronary artery disease, but it has since become apparent that there are illegal drugs being supplied and used by patients within the hospital. The coroner issued her report to St Andrews Healthcare, CQC and West Midlands Police stating:

There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible in the future.

For a couple of years now I have been keeping track of Prevention of Future Death reports. I read them every quarter when I’m disciplined (every 6 months if I can’t face it quarterly). Each report published on the Ministry of Justice webpage, searching to identify whether it relates to someone with a learning disability or an autistic person. This isn’t always easy to identify, I know that the PFDs I capture would no way be the complete picture, because someone’s disability or neurodiversity may not be mentioned. There is always a smattering of labelling people as having a ‘learning difficulty’, some people who are waiting assessment (in which case I include them) and another favourite, people labelled as having ‘traits of autism or Asperger’s’, all of which is unclear to interpret but I have included in my own analysis. It does paint something of a picture of the ongoing risks faced by people though, and unsurprisingly they often map to the leading causes of death for this group.

Inquest’s latest campaign is called No More Deaths and it’s asking for a National Oversight Mechanism to be introduced, a body who would collate, analyse and follow up on recommendations made in PFD reports. On their website there’s a link to a petition to sign and a template letter to send to your MP if you’d care to support their request. This approach would be far more rigorous, better resourced and more wide ranging, than anything I manage to do.

In 2023 there were 558 Prevention of Future Death reports published on the Ministry of Justice website (there may have been more issued, not all are published and this relates to when they made it to the website, not when the person died or the inquest concluded). My searching suggests that of those 29 related to an autistic or learning disabled person, just 5%. Breaking that down further 13 related to people with a learning disability (who may or may not also be autistic) and 16 related to autistic people who died as a result of their mental ill-health in one way or another. [It goes without saying that the content of many of the other 500+ PFDs are likely to be relevant to learning disabled and autistic people as well, but my analysis is to identify anything specifically about their care or support).

In this post I’ll highlight the content of just two of the PFDs issued last year, both relating to the deaths of people with a learning disability. I’ll try to report on the other PFDs in due course.

Lugh Baker

Lugh was a 24 year old man with Angelmans Syndrome and epilepsy who died in April 2021 in the residential care home where he lived in Launceston, Cornwall called Rosewood House. Coroner Andrew Cox recorded an open conclusion, and that the cause of Lugh’s death was unascertained.

On 21/4/21, he was given prescribed medication with a chocolate milkshake at about 20:00. He was checked upon subsequently before being found unresponsive at about 23:30. CPR was initiated during the course of which an unsealed, partly-consumed chocolate bar was seen under or near his bed. Lugh had a care plan that mandated he should not eat unsupervised and should eat sitting up. It is not known how the chocolate bar came to be found where it was. It is further not known if Lugh had been eating it immediately prior to his death. 

Lugh could not be resuscitated. A post-mortem examination did not reveal evidence of airway obstruction. The evidence did not further or fully explain the means whereby the cause of death arose.

The coroner raised a number of ongoing concerns including what processes were in place for staff to familiarise themselves with the care plan of a new resident and whether care plans were reviewed sufficiently promptly for new residents. He also raised a concern which will be familiar to many:

I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh. I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form.

In their response to the coroner Lugh’s care provider, Bowden Derra Park Ltd, via their legal representatives, told the court that the Nocturnal CCTV Monitoring Chart, the Care Plan Policy and the Training Policy had all been updated since the inquest. They also suggest, respectfully, that it would be inappropriate to publish their response or the enclosures as it contains “reference to and copies of internal documents”. The response is published, the enclosures are not.

David Hemmings

David was 73 when he died in June 2021 following complications of surgery he had as a result of an accidental fall in his home the previous January. His care was provided by Choice Support.

David’s PFD tells us that he had a severe learning disability, dementia, poor mobility and visual impairment. It also tells us that there were “severe staff shortages” that meant the manager of the home had worked 36 hours without a break, and there was only a “skeleton crew” working on 12 January 2021, the day David fell. This meant that David was not receiving the 10 hours contact time he was allocated each day, and instead was checked every half hour during the day and hourly at night.

David was living in a flat within a complex. There was a communal area. Due to pandemic restrictions no communal activities were taking place and he became increasingly socially isolated, exacerbated further by reduced staff availability. He was able to get up unaided and walk but had coordination difficulties worsened by visual impairment and dementia, such that he required the assistance of 2 persons to move around.

The coroner noted the following in terms of what happened:

Records suggest that he was checked and found asleep at 0750 hours.

At approximately 0800 on 12th Jan 2021, a support worker entered the complex and heard David calling out in a distressed manner. This worker attended David’s flat and found David sat on the floor in hall behind his front door. The worker called for assistance from the manager and together they lifted and supported him to walk backwards to the chair in his bedroom. He was latter assisted to his bed. It was only when he refused at about 10:30 to stand off his bed and was distressed that another manager was consulted and medical assistance sought.

David was unable to communicate verbally due to his learning disability and had not indicated any particular area of pain on his body.

However the injuries that he had sustained in the fall were severe with multiple pelvic fractures and an impaction fracture of the right head of femur. The pelvic fractures involved the hip joint such that the femur was displaced through the pelvic bones into the pelvic cavity. The evidence of the surgeon was that David would have unable to weight bare on the right and could not have been moved without being lifted and with considerable assistance.

Those staff that had moved David would have had to have provided this assistance.

To move an injured person in this way when they were unable to weight bare was unsafe, could have exacerbated any injuries, and was against the training in moving and handling following a fall that those two staff would have received.

She recorded that the surgeon had given evidence that in this case, moving David had not contributed to his death, but she remained concerned.

The support worker in evidence could hardly remember what training he had received in relation to moving and handling following a fall. At the time, during the pandemic, the training would have apparently been eLearning and video watching for the support worker. The manager was said to be experienced and committed to his work; however both these staff acted outside their training and moved a severely injured man in a way which could have exacerbated his injuries and would have caused him severe pain.

It was only when a second manager became involved that clinical care was sought.

I can not imagine what pain David must have been in for the 3 hours before that second manager got involved, and called an ambulance because David was “distressed and unable to walk”. These staff had received mandatory training, and it clearly made no difference to their practice. Just another red flag for those who think making training mandatory is a panacea for all things.

In issuing the PFD to Choice Support, the coroner states that she believes action should be taken to prevent future deaths, and that they have the power to take such action. In the matters of concern section, she states the following:

That the training given to both the manger and the support worker was insufficient and unmemorable, such that it was disregarded when it was required, and that moving injured people in such a way could worsen injury and endanger live.

David’s PFD was issued on 18 December 2023 and respondents have 56 days to reply, there is no response from Choice Support publicly available yet.

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