Peter Seaby: Poor supervision could have led to care home death

Inadequate food preparation and supervision possibly contributed to the death of a care home resident in need of soft food, a coroner has concluded.

Peter Seaby, 63, lost consciousness after a meal at The Oaks and Woodcroft in Mattishall, Norfolk, in May 2018 and died the following day.

An inquest heard a slice of carrot was found in his throat after his death.

Senior coroner Jacqueline Lake said she had ongoing concerns and would prepare a Prevention of Future Deaths report.

The conclusion comes after an earlier inquest found Mr Seaby, who had Down's Syndrome and difficulty swallowing, had died of natural causes.

His family won a judicial review against its findings and on Friday said they "owed it to Peter to get justice".

The four-day hearing in Norwich was told he was admitted to the care home under a court protection order in November 2017, having previously been cared for by his sister.

He was assessed as requiring a soft, moist mashed diet along with one-to-one supervision when given any food and drink.

Not following this plan would put him at risk of aspiration - the breathing in of food into the airways - and asphyxiation, the inquest was told.

"I have heard evidence that Peter Seaby was not given food that complied with his care plan and that he was not provided with supervision in compliance with his care plan," said Mrs Lake.

On the day before his death, Mr Seaby fed himself shepherds pie across a dining table from a carer looking after someone else.

During the afternoon he deteriorated.

He was admitted to the Norfolk and Norwich University Hospital, where he never regained consciousness and died of aspiration pneumonia the following day.

Mrs Lake said she was of the view his death was not directly caused by the two-centimetre slice of carrot, but that aspiration had occurred during lunch, which was when he had eaten the carrot.

"He was not supervised one-to-one, with someone watching him eat," she added.

"Had he been, I am satisfied the slice of carrot would have been there to be seen and he would've been prevented from eating it."

Mrs Lake said she could not make any findings of neglect, as requested by the family, because Mr Seaby was given nourishment and medical attention.

She noted there was no "debrief, lessons learned or staff training" after a serious incident in which Mr Seaby brought up food from a roast dinner just weeks before his death.

Referring to her Prevention of Future Deaths Report, which is solely directed at the home, she said she was concerned it still adopted an informal approach to supervision and staff rotas, five years on from Mr Seaby's death.

It was unclear whether there were now sufficient staffing levels in place, she said, and no evidence of a review following Mr Seaby's death.

Following the conclusion, the family released a statement which described Mr Seaby as a "lovely, fun, cheeky chap".

"We hope that the one thing that comes out of this is that lessons are learnt and steps are taken by the Priory Group and Norfolk County Council to avoid anything like this happening to another vulnerable individual," they added.

A spokesperson for the Priory Group home said they "would like to reiterate our sincerest condolences to Mr Seaby's family and friends" and would study the coroner's comments "to see if there is further learning".

"We have already improved and enhanced the checks to ensure meals are prepared in line with residents' care plans, as well as improved supervision of residents at meal times, ensuring that carers are confident in following the care plans," they said.

"This sad death happened in 2018 and, during this intervening time, processes have consistently been improved and are robust and comprehensive."

The county council has been approached for comment.

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