Unhealthy culture at seizure death firm - coroner

There was an "unhealthy culture" at a care company, a coroner said, after a woman with learning difficulties died at a residential home following a seizure.

Holly Goodchild, 29, died at Cygnet House in Belton, near Great Yarmouth, on 29 March last year.

At Norfolk Coroners' Court, senior coroner Jacqueline Lake made a narrative ruling and said care plans "were not always followed by care staff", but she could not make a finding of neglect.

Holly's father Paul Goodchild called the ruling "an absolute disgrace". Bosses at Crystal Care, which runs the site, told the BBC they had made "considerable changes" since her death and the company had "moved on significantly".

Cygnet House is a residential home for people with learning disabilities, autism and mental health needs.

Ms Goodchild was living there having been diagnosed with learning disabilities, personality disorder, morbid obesity and epilepsy.

The court heard she had not taken her epilepsy medication on the day of her death and had been found on the floor at about 20:00 GMT.

Initially carers did not give her first aid because they thought she was "attention seeking" and "pretending", the inquest heard.

Ms Goodchild's medical cause of death was given as positional asphyxia, epilepsy and morbid obesity, and left ventricular hypertrophy.

Ms Lake said there were "many concerns" raised in the evidence and there was "an unhealthy culture which had developed at Crystal Care at the time of Holly's death".

But she said she would not issue a Prevention of Future Deaths report, after company director Jennifer Grego assured her Ms Goodchild's death had been taken seriously.

Speaking after the ruling, Mr Goodchild told the BBC: "We lost our daughter and [we think] she could have been prevented from dying - it is disgusting.

"She was beautiful, bubbly, fun, clever, cheeky, really kind, intelligent. She was a fantastic kid and I am proud to be her dad."

Her sister Karla added: "Just because you are in the system doesn't mean you don't have a right to be treated as a human.

"I just want people to know who she was and what a character she was, and I hope lessons are learnt and people get the care they should receive."

Crystal Care said in a statement: "At the time the organisation was facing serious issues, which were reflective of the wider care sector.

"We continue to work closely with the Quality Assurance Team at the local authority and we remain committed to the ongoing improvements across the services.

"Our priority is the safety and wellbeing of our service users. We express our sincere condolences to Holly's family."

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