Cawston Park: Failed hospital's directors still working in residential care

The directors of a specialist hospital where a litany of failings led to a man dying are still in charge of two companies offering residential care, a coroner's report said.

Ben King, 32, had been a patient at Jeesal Cawston Park in Norfolk prior to his death in July 2020.

He died after an obesity-related breathing disorder was not correctly diagnosed.

Jeesal said it has closed the hospital and runs no other hospital services.

The details of Mr King's death have been revealed in a Prevention of Future Deaths Report written by the senior coroner for Norfolk, Jacqueline Lake, following an inquest on 9 July.

The inquest concluded Mr King died from respiratory failure, but identified a number of failings in his treatment including not diagnosing a breathing disorder called obesity hypoventilation syndrome.

Cawston Park, in Cawston, near Aylsham, closed in May, having been placed in special measures by Care Quality Commission (CQC) inspectors in 2019.

The CQC said the closure followed "consistent failures in meeting standards".

Mrs Lake said despite the failings related to Mr King's death, the directors of Jeesal Akman Care Corporation, which had run Cawston Park, were still serving on the boards of Jeesal Holdings and Jeesal Residential Care Services.

The coroner said these companies "provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability".

The report said no substantive changes had been made at residential homes owned by those two companies following Mr King's death.

Mr King had been detained at Cawston Park under the Mental Health Act in 2018.

The coroner's report said he had Down's Syndrome, severe learning disability and sleep apnoea.

Prior to his death his weight had risen from 85.2kg (13.4 stone) in June 2019 to 106kg (16.7 stone) a year later.

He had been admitted to Norwich and Norfolk University Hospital (NNUH) three times in July 2020 following respiratory problems, but was discharged each time.

On 28 July 2020, at Cawston Park, he was given a sedative after showing signs of agitation, but, the report said, had felt unwell in the early hours of the following day.

Emergency services were called after he became unresponsive, but he died at NNUH.

The report said CCTV viewed at the inquest showed Mr King had been assaulted in the hours prior to his death, and one-to-one observation had not taken place, although the report did not go into more detail.

The coroner raised concerns about Mr King's weight gain, including basic dietary advice not being followed by staff, training involving a dietician having been reduced to a one-hour slideshow-style presentation, and a lack of record-keeping and regular exercise.

In November 2020, a separate inquest found staff at Cawston Park had not attempted to resuscitate 36-year-old Joanne Bailey, who died at the unit in April 2018.

The report also criticised NNUH for failing to properly assess Mr King during a series of admissions.

Ms Lake said he had been seen by a number of different consultants, who had each been unaware of his other visits and ongoing treatment.

The report also said "unclear and contradictory" advice had been provided when he was discharged.

Following the inquest, Mr King's mother, Gina Egmore, who had looked after him for the first 30 years of his life until she became unwell, said: "I expected he would be properly cared for when he was transferred to Cawston Park.

"However, the evidence heard at the inquest suggests this clearly wasn't the case."

In a statement, Jessels' board of directors said: "We have since closed the hospital and have no other hospital services.

"Our community services have provided care across Norfolk for over 30 years and while these services differ greatly from the services at Cawston Park Hospital, there are clear lessons to be learned."

It added policies regarding weight management "will be at the forefront of our care moving forward".

NNUH said any recommendations would be "incorporated into our clinical governance and learning processes".

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