Matthew was a 43 year old male with multifaceted and complex needs. He had significant learning disabilities, autism, visual impairment and bi-polar affective disorder. Matthew lacked capacity to make decisions for himself and was the subject of DOL (deprivation of liberty) safeguards. He was a resident at Vancouver House, operated by The Priory.

From an early age Matthew had a propensity to place non-food items into his mouth which presented as a choking risk.

HM Coroner Kate Ainge found the following as part of her conclusion:

There was a clear misunderstanding between commissioning authorities about Matthew’s care needs and the funding and provision of care, commissioners understanding Matthew requiring constant supervision with a provision for 1:1 care 8am-8pm and ongoing waking hours supervision outside of those hours as part of the funding package. The reality was Matthew was provided with 1:1 care 8am-8pm and after that time 1:1 care when eating and hourly observations thereafter that being the assumed regime of care by Vancouver House.

On the 15/12/2020 and 26/12/2020 Matthew was noted to have accessed his incontinence pad and had on at least one occasion prior to death ingested part of it. Whilst some staff had an awareness of Matthews’s risk to put non-food items in his mouth, others did not. Whilst recorded in Matthews’s daily notes, these concerns were not properly escalated to senior management, and this provided a missed opportunity for Matthew to have increased supervision levels on an urgent basis and until a multidisciplinary team meeting could be confirmed to reassess and consider his needs.

Matthew’s family said the following in a statement:

“Matthew was a vulnerable adult. He was unable to defend himself, care for himself, wash or dress himself he was reliant on others for all aspects of his care and safety. To this end Matthew needed an effective and accountable service to keep him safe and to provide all of his care needs. The care system in the UK is in place to protect the most vulnerable people in society, like Matthew. Matthew died because those charged with providing his basic safety needs, failed to do so. His death was entirely preventable. Matt was a much-loved son to me and Gill as well as his mum and step father. He was a dearly loved big brother to his 3 brothers and 3 sisters. We want to remember Matthew for his mischievous nature, his wicked sense of humour, love of food and music, not the horrific and avoidable nature of his death. Matthew’s death was avoidable as were many other deaths that have occurred in The Priory Group facilities. The Priory Group must be held accountable for their failings in a meaningful way so that no other vulnerable adult and their families have to go through this.”

The family were represented by Gareth Naylor, Director and Head of Inquest Law at Ison Harrison Solicitors and Richard Copnall of Parklane Plowden Chambers.

Gareth Naylor stated:

Matthew was an extremely vulnerable man with many disabilities. We heard evidence of some good care from staff on the ground at Vancouver House, playing games and having fun with Matthew which provided the family with some comfort.

However, what was of great concern was the complete lack of clarity in relation to what care Matthew required and the risks he posed to himself. Despite incidents occurring (Matthew placing non food items in his mouth) on the 15th and 26th December, these events were not escalated and Matthew choked to death on his own incontinence pad, whilst unsupervised, and died on the 27th December.

There were missed opportunities to reconsider Matthew’s care needs.

I am disappointed that the Coroner found that the failings in this case did not amount to neglect or a breach of Article 2 of the Human Rights Act as in my view, the failures in this case went beyond mere medical negligence. We await the Supreme Court decision of Maguire on this specific issue.

Matthew’s family have shared stories of Matthew with me which have brought a smile to my face and a tear to my eye at times. I’m told Matthew had great character, loved to laugh and was a cheeky chap. It has been an honour to represent Matthew and his family.

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