A disabled man who choked to death on his own incontinence pad at an "inadequate" care home was not neglected, a court ruled.
Matthew Dale, who had severe learning difficulties and autism, was left unsupervised in the dining area of Vancouver House on Vancouver Road, Netherley, on the night of December 27 2020, during which time he tried to swallow a piece of his own incontinence pad.
A member of staff noticed him coughing and he was slapped on the back. However, the 43-year-old then soiled himself, and staff turned their attention to cleaning him up. They took him to his room, where thrusts were administered, but these were ineffective due to Matthew's size. He then fell unconscious and was given CPR by both nursing home staff and paramedics, but he could not be revived and died at the scene.
READ MORE: Disabled man choked to death on incontinence pad at 'inadequate' care home
At his inquest on Wednesday, January 25, Coroner Kate Ainge found Matthew had not been neglected by staff prior to his death, and that Article 2 of the European Convention on Human Rights Act, the right to life, had not been breached. She found the vulnerable 43-year-old died of a misadventure, contributed to by a missed opportunity to identify his needs.
In a statement, his heartbroken dad Stuart said: "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."
The court previously heard that Matthew, who came from Warrington, had been living at Vancouver House for nine years and received one-to-one care between 8am and 8pm each day, funded by Warrington Council from 2011 until September 2018, and then by Liverpool CCG when the authority took over his care. It was understood by the commissioners the care was to be given on top of what was already provided by Vancouver House staff - but home managers said they believed this was the only care they were supposed to provide.
As a result, Matthew did not receive one-to-one care during all waking hours, and was instead given only hourly checks between 8pm and 8am.
However, the coroner ruled that this was a "breakdown in communication" between the commissioners and care providers that did not amount to a systematic failure. She also found there were no operational failures which presented a "real and immediate" risk to Matthew, as there had been no clinical presentation of him putting non-food items into his mouth from 2012 to December 2020.
There had been missed opportunities to increase his levels of observation after he was seen trying to ingest non-edible items on December 15 and December 26 2020, as these incidents were not properly escalated. The court previously heard that, if they had been, Matthew's checks would have been increased from hourly to every 15 minutes. However, this was not sufficient to determine that his life would have been saved.
The coroner dismissed neglect, as Matthew had not suffered a "total and complete" lack of care, "simply not what was expected by the commissioners". She indicated she may issue a Prevention of Future Death report to the Secretary of State for Health and Social Care regarding the miscommunication, however.
Vancouver House was placed under investigation by Liverpool City Council following Matthew's tragic death.
It was rated "inadequate" by the CQC in August 2021, and was later shut down by The Priory Group mental healthcare providers, with bosses citing "significant staffing challenges".
Stuart said: "Matt was a much-loved son to me and his stepmum Gill as well as his mum and stepfather. He was a dearly loved big brother to his three brothers and three 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.
"The coroner found there were missed opportunities to provide for Matthew's know care needs and that this contributed to his death. We agree with this finding. Matthew’s death was avoidable as were many other deaths that have occurred in The Priory Group facilities.
"The Priory Group have to be held accountable for their failings in a meaningful way so that no other vulnerable adult and their families have to go through this."
They welcomed the possibility of a Prevention of Future Death report.
A Priory Group spokesperson said: “We would like to express our deepest condolences to Matthew’s family for their loss. Although the Coroner returned a conclusion of misadventure, we will consider her findings carefully to see what lessons can be learned. The home was closed in September 2021.
"Priory cares for more than 25,000 people a year, across our hospitals and residential homes, and unexpected deaths – which are a tragedy for family and our staff wherever they occur - remain rare. Safety remains our foremost priority.”
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