I do not have an extensive biography for Rachel as I was unable to connect with her family and speak to them before her inquest; for that same reason I chose not to live tweet it, instead blogging daily. What we did learn during the course of Rachel’s inquest was that she was usually happy, she woke early and started each day singing. We heard how she loved a party and was always happy, brightening everyone’s day.

The Coroner found that Rachel died as a result of complications of necessary surgery, to which neglect contributed.

On 26 October 2018 Rachel Johnston, who had significant physical and learning disabilities, underwent necessary and extensive dental surgery under general anaesthetic. Having been discharged that evening to Pirton Grange Nursing Home, where she lived, she developed aspiration pneumonia which resulted in her re-admission to hospital with an unsurvivable hypoxic brain injury

Rachel died on 13 November 2018.

Nursing staff a Pirton Grange failed to carry out adequate physiological observations on Rachel after her discharge from dental surgery, and failed to seek emergency assistance.

Had emergency assistance been sought she probably would have survived and not died when she did.

On 26 March 2021 the Coroner decided he’d issue a Prevention of Future Death Report.