Jared was Vicky’s first born, arriving on 20 February 1994. Vicky was a young mum, only 19, but very excited for the future. Jared was a perfect baby, he didn’t cry a lot, he slept and fed well, but at his 6 month check-up there was concern he wasn’t putting weight on.

From that point on Jared received support. They had input from physiotherapists, occupational therapists and a speech therapist at their home, along with a brilliant community paediatric nurse.

Jared started to receive overnight feeds from about 9 months. Everyone loved working with him, he was such a gorgeous boy and tried his hardest to do what was asked of him. When Jared was six, coming up to seven, his sister was born, and a few years later his brother arrived.

Jared loved being a big brother and had a very, very close bond with his little brother. They used to enjoy watching SpongeBob together, playing with lego and as they got a little older playing two player PlayStation games.

Jared had an electric wheelchair and Jared’s younger brother used to stand on the back of it as Jared left the house and went to the school bus each day. He’d spend the afternoon waiting for him to come home so they could do the same journey in reverse.

Vicky and her daughter rode horses and Jared would go up to the stables with them occasionally, and he’d often be cold and end up wrapped up in lots of blankets.

Vicky was a single parent and didn’t have a lot of spare money, but they had a lot of love and a happy home and Jared had a great relationship with his grandparents. Jared was diagnosed with a metabolic disorder, and learning disabilities, and attended his local special school.

Jared didn’t let anything get in his way of having a good life though. He remained small throughout his life, but also had an enormous appetite, he’d eat everything and anything except apples, he drew the line at them, unless they were in a pie.

Jared lived at home with his mum, his sister and brother until he was 18. Like any family, they knew each other well, and supported each other. They were a close family unit.

Without Vicky’s knowledge, a social worker visited Jared at school when he turned 18 and conducted a Mental Capacity Assessment, which she has never seen. This assessment deemed Jared to be capable of making his own decisions.

One day Jared left for school and asked a seemingly innocuous question, when was he going to Yew Trees again? (The respite service Jared loved, they did lots of fun things they couldn’t necessarily afford as a family, trips to the seaside, or the cinema, that sort of thing).

Vicky didn’t think anything of it. Jared never came home from school that day. Apparently Jared had mentioned at school he was unhappy at home, and because the social worker deemed him capable of making his own decisions, they were not returning him home.

Jared went to Yew Trees to start with. Vicky visited him and he talked about coming home. Then there was a meeting called with lots of professionals present. At the meeting they said to Jared: ‘You’ve a couple of choices, you’re old enough to make your own decisions, you can go home or go to somewhere like Yew Trees called Ability’.

Jared choose Ability. Vicky felt she had to support his decision, he was growing up, if that’s what he wanted, who was she to stop him?

Vicky was never asked to contribute to any handover, no-one asked her about Jared’s like and dislikes, his medical condition or needs. She felt like they didn’t want her involved and the atmosphere was often difficult when she visited Jared.

Jared left school in June after he turned 19 and moved to a supported living bungalow the following September. Vicky worked full time, and still had two children to support, but would visit Jared as often as she could on her days off and they’d go out and do things.

Vicky and Jared would visit Meadowhall Shopping Centre. She’d take him to get his hair cut, that sort of thing. Jared started talking about wanting to come home, but Vicky felt certain it wouldn’t happen because the care provider was being paid a lot to look after him.

The last time Vicky saw her son alive was Christmas 2014.

Jared had been at the centre of their family, safe and well and loved in their home for 18 years, and after less than two years in the ‘care’ of Ability, he was dead.

Vicky spoke to Jared on New Year’s Day 2015.

On January 4 2015 Vicky woke at 7am to a text message from a number she didn’t know.

The message, sent the night before around midnight, stated Jared had been taken poorly and was currently en route to A&E in an ambulance, and they’d ring her as soon as he arrived at the hospital.

No-one rang Vicky. There were no missed calls. Alarmed she rang his carers to check if Jared was still in hospital.

The phone was passed to the manager who informed her over the phone that Jared had died at 1am in hospital. At this point he had been dead for 6 hours.

No-one contacted Vicky. No-one gave her the chance to be with her son in the last moments of his life. She expressed how no parent should have that choice taken away from them. Nothing can ever prepare you for that pain.

It is now coming up to six years since Jared died and Vicky has fought tirelessly for answers about why her son died, suddenly, at the age of 20 with no life-limiting conditions. Since Jared died they’ve learned he became unwell on Jan 2nd and over the following days his condition did not improve. Apparently medical advice was sought from Jared GP surgery and he was diagnosed with diarrhoea and vomiting. This was despite the local hospital advising Jared must attend hospital if he became unwell, this did not happen until a few hours before his death.

A Serious Incident Report conducted by NHS 111, out of hours GP service suggests Jared should have been taken to A&E sooner and found the carers had been given inaccurate advice about the symptoms of sepsis.

Jared’s inquest was eventually held 7 years after his death in March and April 2022. The coroner, Peter Nieto, found that Jared died due to bowel obstruction and ischaemia, likely related to abdominal adhesions due to abdominal surgery performed when he was a child. The development of adhesions following surgery is a common medical complication. The coroner explained that while surgery wasn’t highlighted in the discussion of evidence in his judgement it clearly needed to be in the conclusion. He said the court had heard evidence that bowel obstruction was likely to be related to the surgery performed when Jared was a comparatively young child… and without the adhesions it was unlikely the obstruction and rotation of Jared’s bowel would have occurred.

The coroner highlighted he’d not mentioned any acts or omissions in relation to the GP, the out of hours service or the support staff in his conclusion. He felt on the evidence he could not find any acts or omissions contributed to his death.

He found this because “on the evidence by the time it should have been recognised that Jared was very unwell, it was likely too late for treatment to be provided to him, that would have avoided his death”.

The coroner said despite not being able to make that finding, he nevertheless thought the inadequacy of the assessment provided by Dr Saroha on 3 January 2015 ought to be recorded in Box 3 of the inquest form. He said Dr Saroha’s assessment “was clearly not the assessment that should have been provided given the information that was or should have been known to him and had been reported to the out of hours service by that time”.

The coroner outlined the wide range of evidence heard in court, stating: “some aspects we’ve not had very clear evidence, or there’s been missing records which has made things difficult for us I think”.

Evidence had been heard from pathologist, Jared’s mum, Vicky, his GP Dr Desai, Nathan Wood, current CEO of Ability Care, support workers who were working the weekend 2 and 3 Jan 2015 and the senior support worker on call over the weekend.

The coroner read evidence from Dr Scriven, former GP, and Anne Lunn, the then registered manager of the home where Jared lived at the time of his death [As an aside she has since been prosecuted for fraud and been struck off by the NMC].

The court also heard evidence from out of hours service staff except Dr Saroha who the Coroner was unable to contact but “as it turned out given the findings I am going to make I don’t see that would have changed anything in particular”.

Also heard from current clinical director of the Out of Hours service, and from two court appointed experts, Dr Mark Burgin instructed by Jared’s family (in part thanks to the generosity of those who supported their crowdfunder) and Mr Chris Challand, who the coroner instructed. The coroner also reviewed a number of records.

The coroner found Jared died at Chesterfield Royal Hospital on 4 January 2015 in the early hours following bowel obstruction and ischaemia and several cardiac arrests. He was just 20.

Coroner heard Jared been in hospital in Oct 2014 due to abdominal pain which according to the discharge letter “had settled spontaneously”.

Jared’s support worker contacted his GP on 2 Jan as Jared was feeling unwell with sickness, diarrhoea and complaining of stomach pain.

Jared had been unwell for at least a day. Dr Desai called back that afternoon, recommended support workers monitored Jared, stopped dioralyte treatment and review Monday if he was no better. Ability records had a written note to contact Out of Hours service if Jared was worse over the weekend.

Next day, 3 January, Jared was no better.

His support worker contacted the Out of Hours GP service that evening at 17:41. She reported to the triage nurse that Jared was a funny colour, had reddish eyes, purple fingers and nails, a swollen tummy, reduced communication and was floppy.

The support worker requested a home visit as they had difficulties getting Jared to hospital and would rather he was admitted straight to a ward, than through A&E. Support worker was under the impression they’d be getting a visit from a doctor.

Instead Dr Saroha called back 6pm, missed call, support worker called back 6:15pm, then Dr S called again 6:30pm. Jared’s temperature was 34.8, he recorded diagnosis of gastroenteritis and said to monitor temperature and call back if it was less than 34.5.

The coroner ruled it was not known if he’d considered the information given to the triage nurse. Night shift were on duty at Ability Care, an hour later the support worker from the day returned as she’d forgotten her bag. She popped in to check on Jared and ended up calling the Out of Hours Service again because she was so concerned.

Jared’s temperature by now was 33.1, he had hot core and cool peripherals. Out of Hours decided he needed an urgent home visit in 2-4hrs. The support worker called an ambulance 20mins later, and went with Jared to hospital.

On arrival at A&E Jared was “noted to be very unwell and went into cardiac arrest”, once stabilised CT scan showed likely adhesion related to a small bowel obstruction. “Sadly Jared had a further cardiac arrest from which he could not be saved”. Jared died at 02:10 on 4 January 2015.

Medical cause of death given for Jared, which the expert concurred with and the coroner saw no reason to change was:

1a acute small bowel ischaemia

1b small bowel volvulus

1c fibrous band adhesions

Coroner went on to consider whether aspects of the medical care or treatment, or social care support, provided to Jared, contributed to his death.

Coroner said that he must “assess evidence in accordance with the test in the coroners court of balance of probabilities… must find probability and not merely possibility” and the relevant period for his consideration was 2 and 3 January 2015.

He commented that we are reviewing the events of Jared’s death in retrospect and have the benefit of hindsight, and have a more complete picture of what did happen and why…. as opposed to what was apparent at the time. The coroner then offered a caveat about limitations.

“I’m aware Jared’s family have concerns about Ability Care and other agencies in provision to Jared and how the family were involved and treated. They may be very legitimate concerns but are not matters for Jared’s inquest, when not related to how Jared came by his death”.

Coroner stated evidence was “notably limited in some areas due to the passage of time… some key statements were written several years after Jared’s death without the benefit of access to records… and now understandably unclear of many details in giving evidence”.

He continued, “seriously incomplete Ability records to refer to… some witnesses were uncontactable or unable to give evidence. This is clearly regrettable… having said that do not see that robbed us of the opportunity to gain understanding about how Jared came by his death”.

The coroner then passed comment on how relevant the expertise of the family’s expert was as he’d not been practising as a GP since 2011. With regard to Dr Desai, Jared’s GP, coroner said “clear to me is certain insufficient information and detail” in his record, which the GP conceded.

Coroner said it “must be for Dr Desai to decide on the need for a home visit using his own clinical judgement” and the coroner felt the provision diagnosis of gastroenteritis was a reasonable one given Jared’s systems and fact another resident had a viral stomach bug.

Coroner then moved onto Ability Care “I made no criticism at all of the support staff, in my judgement they sought medical advice appropriately as and when their concerns increased”. He said he’d no reason to consider lack of basic medical care and skills.

Coroner found that the Out of Hours GP service staff “should have reached different decisions”.

He found the triage nurse “should have made greater inquiry, nevertheless she identified the need for doctor assessment”. The court heard from Dr Saroha that triage notes were not easy to access.

And Dr Saroha did not access them.

Court didn’t have a recording of Dr Saroha’s consultation but Jared’s temperature was 34.8, potentially hypothermic, cold peripheries and other factors “that might be concerning on clinical review”.

The experts considered home visit or a non-emergency ambulance should have been requested. Expert considered “Jared was clearly unwell with indications of peripheral shut down” and he was unable to state was “more likely than not Jared’s death would have been averted if an ambulance were called” so the Coroner found an ambulance would not have prevented Jared’s death.

Coroner found Jared’s condition was serious by 18:30 but that the physical reserves he had to resist it would have been limited. On balance of probability Coroner felt alternative decisions would not have prevented Jared’s death, so he could not identify as contributory.

Coroner said “in retrospect it was likely Jared was suffering an evolving bowel obstruction by 2 Jan 2015” He accepted the Out of Hours doctor service should have arranged an urgent home visit or requested a non emergency ambulance to attend at 18:30. The doctor did not arrange either.

However, the coroner concluded it was “unlikely Jared’s death would have been avoided due to his critical state at that point and insufficient time to provide life saving treatment in hospital”.

Jared was eventually taken to hospital at 22:30, following two cardiac arrest he died at 02:10 on 4 January 2015.