Peter Seaby: Risks remain after man’s death potentially linked to issues at care home

A coroner has raised concerns after a care home resident's death was possibly linked to poor supervision and food preparation.

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

In a report the coroner raised concerns about "informal care" at the home.

"The safety and wellbeing of residents is our foremost priority," the Priory Group home said.

Mr Seaby entered the care home in 2017 and was assessed as requiring a soft, moist, mashed diet along with one-to-one supervision when given any food and drink.

At the inquest Senior Coroner for Norfolk Jaqueline Lake said there was evidence Mr Seaby was "not given food that complied with his care plan" and he was not provided with correct supervision.

Mr Seaby had Down's Syndrome and had difficulty swallowing.

During evidence it emerged a slice of carrot was found in Mr Seaby's throat after his death.

In her report Mrs Lake said she was concerned an internal review had not been carried out by the home in the nearly five years after the death.

The inquest heard evidence of steps the home has subsequently taken but the coroner raised concerns after current staff spoke of still providing care on "an informal basis".

She also said it was not clear if staffing levels, including for residents needing one to one supervision, was sufficient.

A Prevention of Future Deaths Report from the coroner followed a second inquest after Mr Seaby's family won a judicial review following the conclusion of the first.

The earlier inquest concluded Mr Seaby had died of natural causes.

It is believed Mr Seaby aspirated on a piece of food he ate at lunchtime and his condition deteriorated throughout the day.

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

A spokeswoman for the home said it was "taking steps" to address issues raised by the coroner.

Those included a full internal review, not initially completed due to Mr Seaby's death being deemed natural causes.

She said: "We have reviewed our staffing levels; they are adequate and what are commissioned for this service.

"There is not an informal basis for allocating meals but we have gone back to review this, in particular, at the home and are assured that there are robust procedures in place with oversight from the local leadership."

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