This is my second post about Prevention of Future Death reports published in 2023 relating to learning disabled and autistic people. You can read the first one, which includes an explanation of what PFDs are here. In this post I’ll cover the PFDs issued following the deaths of Owen Garnett, Steven Duquemin and Matthew Dale which all involve people with a learning disability dying as a result of choking whilst unsupervised.
Owen was a 19 year old young man with a severe learning disability who attended Welcombe Hills Special School in Stratford upon Avon, which is part of the Unity Multi Academy Trust. The coroner for Warwickshire, Linda Lee, records in the PFD that Owen had “numerous health problems” including difficulty swallowing and Pica. Pica is the eating or swallowing of non-food substances, and in Owen’s case the school were aware of the risks this presented to him:
Because of this tendency [Pica], Owen needed to be constantly watched to ensure that he did not eat such items. This was recognised in the school’s risk assessments which initially recorded that Owen should ‘Never be left alone when out’ and to which was later added in bold ‘NB due to Pica, a named person must watch Owen at all times, to ensure he doesn’t eat anything particularly leaves and twigs.
However, his carer noted that Owen was consuming items whilst at school such as twigs and other non-edible items. She raised this issue with the school on many occasions over a number of years. She was monitoring his stools and had photographs of such items in his stools. She sent the photographs to the social worker and believed they had been forwarded to the school. The school say they did not receive the photographs, but they were certainly aware of her concerns. In November 2022, Owen’s carer specifically raised concerns surrounding blue paper towels at a meeting attended by Owen’s class teacher.
So often when I speak with bereaved families and they describe the circumstances of their loved one’s death, they report predicting that it would happen, and not just predicting it but sharing their fears with people who had the possibility to prevent it, all to no avail. I can not imagine how Owen’s carer must feel. There’s the failure to keep Owen safe, sure, but there’s also the failure to listen to his carer and respond appopriately.
On 4 January 2023 Owen was discovered to have blue paper towel in his mouth and a message was sent to his carers saying this had occurred. A near miss report made but no action was taken as a result of the report.
On 9 January 2023, contrary to the requirements of his risk assessment, Owen was outside of the classroom and was unsupervised. When Owen was located, it was discovered that he had crammed a significant amount of blue paper towel into his mouth and throat and was choking.
Resuscitation attempts were made, and Owen was transported to Warwick Hospital. Owen had suffered a hypoxic brain injury. A decision was taken to remove life support and he died on 11 January 2023.
Owen was 19. The coroner concluded his death was due to misadventure. She identified a number of ongoing risks:
The evidence showed that the concerns of Owen’s carers were not acted on. Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers. The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded.
Had Owen been supervised as envisaged in his risk assessment, he would not have been able to consume the significant quantities of blue paper towel found in his mouth and throat. The class teachers’ evidence was that after her initial training, the process of advice on prioritising of supervision was retrospective in that she only received feedback on events that had already occurred. The current plan appears to permit the class teacher to deviate from the planned supervision and prioritising of supervision in circumstances that are not made clear.
The Health and Safety Inspector present at the inquest indicated that the Inspectorate had not had the opportunity to review the plan and would be considering whether to participate further by reviewing the implementation of the plan. However, as the relevant inspector could not be present, it was unclear when the plan could be reviewed and by whom.
Welcome Hills had up until 2 January 2024 to respond to the PFD report. No response has been loaded onto the judiciary website yet. As an aside Ofsted conducted an inspection in November 2023, 10 months after Owen’s death and rated the school as Requires Improvement, whilst stating this about safeguarding:
The arrangements for safeguarding are effective.
Leaders are diligent in safeguarding pupils and are tenacious in following up any concerns. Staff are trained to spot any signs of potential harm and report them.
Consequently, pupils get the support they need to stay safe. The school ensures that families are well supported.
I have not been able to establish how old Steven was when he died in August 2022, but the coroner for Blackpool and Fylde, Alan Wilson, described him as “vulnerable man who died at a relatively young age”. He sent a PFD to Northern Care Ltd trading as Ubu, his care and support provider.
Steven was autistic, had a “mild to moderate learning disability” and he also had epilepsy. Steven was last seen alive, in his flat “shortly after 8pm” on Sunday 28 August 2022. The following morning, shortly after 9am, Steven was found dead in his flat, sat in a chair. The coroner recorded:
He had been deceased for a number of hours. A subsequent post mortem examination revealed that he had been eating raw chicken at some point overnight when a significant piece of which had become stuck in his airway, that he began to choke, and he suffered a fatal lack of oxygen to the brain. Steven resided in accommodation which is a community-based, domiciliary-type property where personal care and support are provided for vulnerable people living independently.
He received help with aspects of his daily care during the day, and overnight he could seek assistance from a member of staff residing elsewhere in the building should he need to.
The risk that Steven could choke on his food had not been fully appreciated, but from the available evidence it cannot be established that a fuller appreciation of the risk would have averted Steven’s death.
In July last year, the coroner concluded that Steven died an accidental death. He said that Steven could access food from his fridge at any time, including when no care staff were present. He also said that Steven had not been checked overnight, even though a Service Manager who gave evidence to the court agreed that should have happened. The coroner found that would not have altered the outcome for Steven.
The coroner raised a number of ongoing concerns in the PFD, including that entries in care records were inconsistent, including “some indicating Steven was not at risk of choking when he clearly was at such risk”. His principle concern related to a Service Manager at Ubu, who’s name he redacted in the PFD. His concerns were as follows:
My concern is quite straight-forward. I received evidence from a Service Manager. In my judgement, in the face of quite overwhelming evidence to the contrary – including a clear medical cause of death reported by the Pathologist – [REDACTED] continued to maintain that Steven had not been at risk of choking, and appeared to stand by entries in care records to the extent they indicated he had not been at risk of choking.
As I indicated at the conclusion of the inquest, it appeared to me that did not feel anything different ought to have been done, and I formed the view that even if some measures were felt to be necessary to assist service users such as Steven, these were not necessarily going to be implemented with the speed which may be necessary to minimise potential risks.
I found [REDACTED] stance surprising, and I determined that there had been an under–appreciation of the level of risk. It creates an obvious risk to other service users when vulnerable people such as Steven are not appropriately assessed in terms of potential risks. It means the necessary preventative measures may not be put in place, and that their lives are at risk as a consequence.
The approach of a relatively senior member of the care staff can, of course, have an impact upon the approach adopted by other personnel and particularly regarding more junior staff.
Ubu were required to respond to the PFD by 16 September 2023, but as yet there is no response uploaded on the judiciary website.
The first time I witnessed an “under-appreciation” like this was at Connor Sparrowhawk’s inquest, where his Responsible Clinician, Dr Valerie Murphy, repeatedly told the court that Connor was not having epileptic seizures, when he clearly was.
Dr Murphy only changed her position when her GMC Fitness to Practice hearing took place.
I can’t help thinking part of the reason learning disabled people die so prematurely, and have done for decades, is because those involved in their care don’t see them as fully human, and even in the face of overwhelming evidence of risk, they remain adamant that they know best. Anyhow, back to recent PFDs.
Matthew was 43 when he died in the Priory run care home where he lived, Vancouver House in Liverpool in December 2020. At the conclusion of his inquest just over two years later, the coroner, Kate Ainge, Assistant Coroner for Liverpool and the Wirral, wrote to Steve Barclay, the Secretary of State for Health and Social Care.
Matthew was described as having “significant learning disabilities”. He was autistic, blind in one eye and had partial sight in his second eye. The PFD records that Matthew lacked capacity to make decisions for himself and he was therefore subject to a DOLS (Deprivation of Liberty Safeguard).
The PFD records that since childhood Matthew was known to put non-food items in his mouth, which presented a choking risk. The coroner described the risk as continuing throughout adulthood, and being “cyclical in presentation”. Matthew lived in sheltered accommodation from 2008 to 2011, when he moved to Vancouver House care home “due to an escalation in behaviours which included in part, ingestion of non-food items on 4 separate occasions in short succession in 2010”.
When he moved to Vancouver House in February 2011, managers knew about the risks that Matthew would ingest non-food items. In September 2011 it was said the risks had “significantly reduced” as Matthew had “settled in his placement”.
Vancouver House changed ownership and with that a change of managers who at the time of Matthews death were not aware of any risks of Matthew ingesting non-food due to no ongoing identification of such risk or assessment of it since November 2011. There were no further incidents of Matthew ingesting non-food items from 2011 until 2020.
As part of Matthews multifaceted and complex care plan, there was a system of reviewing Matthews care provision and a protocol for escalation of concerns around safeguarding or meeting his care needs to the agencies and professionals involved in his care.
Regular and statutory reviews of Matthews care provision and placement were undertaken. No concerns were raised about risks to Matthew of the ingestion of non-food items or the provision of his care needs.
There was a clear misunderstanding between commissioning authorities about Matthew’s care needs and the funding and provision of care, commissioners understanding Matthew requiring constant supervision with a provision for 1:1 care 8am-8pm and ongoing waking hours supervision outside of those hours as part of the funding package.
The reality was Matthew was provided with 1:1 care 8am-8pm and after that time 1:1 care when eating and hourly observations thereafter that being the assumed regime of care by Vancouver House.
I’m left wondering how many years Warrington Borough Council, and then Continuing Healthcare funding, were paying for the provision of care and support, that was not actually provided to Matthew. I’m also left wondering why the hours 8am-8pm were chosen in the first place, are those the times within which a 40 year old is meant to be out of their bed?
On the 15/12/2020 and 26/12/2020 Matthew was noted to have accessed his incontinence pad and had on at least one occasion prior to death ingested part of it. Whilst some staff had an awareness of Matthews risk to put non-food items in his mouth, others did not.
Whilst recorded in Matthews daily notes, these concerns were not properly escalated to senior management and this provided a missed opportunity for Matthew to have increased supervision levels on an urgent basis and until a multidisciplinary team meeting could be confirmed to reassess and consider his needs.
Had the incidents on the 15 and 26 December have been properly escalated, Matthew would have been on 15 minute observations, he was in fact on hourly observations and when unsupervised Matthew placed a piece of his incontinence in his mouth and swallowed it.
As a result, the piece of pad expanded with the saliva and became trapped in his airway. Staff at the home staff engaged backslaps which failed to dislodge the item in question, Matthew was then incontinent of faeces and concerns were turned to attending to his personal needs rather than the serious choking risk and Matthew was taken to his room during which no further attempts were made to dislodge the choking item until his personal care needs had been met.
Thereafter abdominal thrusts were noted to be given but ineffective in part due to difficulties undertaking the manoeuvre due to Matthews size and also due it being unlikely that such actions would have in any event dislodged the item. Emergency services were contacted and upon Matthew becoming unconscious CPR was commenced, taken over by paramedics upon arrival. Paramedics were able to remove the piece of pad from Matthews throat by forceps. Matthew died from placing the piece of pad in his mouth during a period in which he was not supervised and in part contributed to by missed opportunity to increase supervision to meet Matthews identified needs.
I remember reading this PFD for the first time and being utterly horrified. I’m still almost lost for words. What were people thinking, taking a man who was choking, to address his personal care needs. Why were the emergency services not contacted immediately? Where is the common sense?
The coroner recorded that Matthew died due to “Misadventure in part contributed to by a missed opportunity to increase supervision to meet Matthews needs”.
It is hard to piece together what evidence was heard in court. In fact it’s not possible from reading a PFD alone. I assume that the coroner heard evidence from those who were caring for Matthew on the day he ingested the incontinence pad, on 27 December 2020. I obviously don’t have the overview that she did, but I’m surprised that there was no PFD raised about staff training in first aid, especially given how many people with a learning disability have difficulties swallowing and die from choking, or aspiration pneumonia.
The barrister representing Matthew’s family had argued that failures in Matthew’s care amounted to neglect, and the care home and commissioners had breached Article 2 of the European Convention on Human Rights, operationally and systematically. He said:
“There are two potential failures which are capable of amounting to negligence. The first is the absence of any system to prevent Matthew having access to his pad, such as the system used by his parents when he was living with them. The second is that Matthew was left alone, unsupervised at the time he put the fatal pad in his mouth.”Parklane Plowden Chambers News Release
The coroner issued a PFD to the Secretary of State stating she believed that he had the power to take action to prevent future deaths. The matters of concern that she detailed were as follows:
It became clear in the inquest that the commission, funding, assessment and provision of care needs is a complex process involving, particularly as in Matthews case, where there are multiple agencies involved due to his own complex and multifaceted needs. In this case it has been established that there was a confusion over the care in how it was funded and expected to be provided, compared to that which was understood to be funded and actually provided on the ground to Matthew. The confusion appears to have arisen over the understanding of a number of care terms and the use of them which has resulted in 2 commissioning agencies and an agency providing the care having differing views about Matthews care and that which should have been in place and that which was in place.
This PFD was issued in January 2023 and a response was required by March 23 2023, but there is nothing publicly available on the judiciary website yet.
Vancouver House was inspected by CQC following Matthew’s death in January and February 2021 and given a rating of Requires Improvement. At that time it was noted that a police investigation was ongoing. CQC returned to inspect again in August 2021, and found that the care being provided was Inadequate. On 22 October 2021 the home closed down with The Priory citing difficulties with staffing being the reason why.
Liverpool Echo have provided local coverage too, of note, Death, sackings and multiple investigations at under fire Liverpool care home published on 17 January 2021 where they had spoken with two whistleblowers who had tried to raise concerns about care being provided to Matthew in the weeks before his death.