The inquest into the death of Peter Dickens (31) concluded on the 28th March 2024 with HM Assistant Coroner, Dr Elizabeth Didcock returning a scathing narrative conclusion.

Peter had a past medical history of autism, severe learning disability with challenging behaviour, choking disorder (Dysphagia) and epilepsy. He was non-verbal but for a few words and short phrases.  He had been in residential care for some time and had moved to The Beeches, operated by Cygnet, in February 2021.

Peter required one to one care and was known to be at risk of choking. He had choked on previous occasions so had a clear eating and drinking care plan. This involved one to one supervision whilst he was eating and that his food should be cut into pieces no bigger than the size of a five pence piece. The care plan required that Peter be fed via a two-plate system in which a carer held one plate with his food and Peter had a separate plate that the food would be placed onto one piece at a time.  Carers were then required to check that Peter had safely swallowed the food before offering another piece.

On the afternoon of 22nd January 2022 Mr Dickens was given a peanut butter sandwich to eat.  Instead of providing one to one support and using the two-plate system, his carer placed a plate of cut up sandwich pieces on his floor and then left the room.

Shortly afterwards, Mr Dickens ran out of his bedroom into the corridor in apparent distress. He banged his head on the wall and fell to his knees. Staff members noticed that he had a quantity of food in his mouth and appeared to be choking. They started back slaps and abdominal thrusts to try and clear the blockage and called the emergency services for further assistance.

Peter went into cardiac arrest and care home staff began cardiopulmonary resuscitation. An ambulance crew arrived a short time later and continued CPR at the scene for approximately 40 minutes before taking Peter to Bassetlaw Hospital with resuscitation attempts ongoing.

Peter was sadly pronounced deceased by hospital staff at 16:47 hours.

The Coroner found that Peter’s Eating and Drinking guideline was not followed, and this led to him choking and to his death.  She found that insufficient weight was placed on communication and Peter’s severe learning difficulties.

The Beeches did not have a chef at weekends (Peter died on a Saturday) which meant that staff were taken away from residents which increased risk.

The Coroner found that staff found it difficult to raise concerns with management which possibly made a more than minimal contribution to Peter’s death.

She found that there was a lack of managerial oversight and a lack of communication between disciplines and MDT meetings.

The Coroner recorded;

Risk of death was a reasonably foreseeable consequence of non-compliance of the eating and drinking care plan.  Peter’s death was contributed to by neglect.

Having considered all of the evidence, I welcome the changes introduced by Cygnet at The Beeches which go some way to reducing the risk.

My concerns remain that Cygnet have not addressed the persistent lack of compliance, lack of understanding by management for this lack of compliance, lack of recording of the strategies used at meal times, failure of the management to monitor compliance.

There is no evidence that demonstrates improvement with this issue and their failure to provide the support funded to Peter, unaware he was funded for 6 hours a day. 2:1 support.

Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.

The Coroner has therefore exercised her powers pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 and will be issuing a Prevention of Future Deaths Report to Cygnet who then have 56 days to respond.

We will provide further updates in due course.

**Update – 31st May 2024***

The Coroner has now issued a scathing Regulation 28 Prevention of Future Deaths Report which can be found here.

The family was represented by our Director and Head of Inquests, Gareth Naylor and Alan Weir of Counsel, Parklane Plowden Chambers.

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