Inquest finds that the death of a vulnerable young adult in a private care home amounts to death by “natural causes”

Thomas Rawnsley’s death is “yet another example of how individuals with learning disabilities are failed in a health and care system ill-equipped to assist adults with complex care needs”.

In July 2014, Thomas Rawnsley, a vulnerable young man with Down Syndrome and Autism Spectrum disorder was placed by order of the Court of Protection in a residential care home in Sheffield, Kingdom House (operated by Lifeways). Thomas had previously been detained under the Mental Health Act at an Assessment and Treatment Unit in Bradford. Due to the unit’s inability to cope with Thomas’ complex needs, the Court of Protection made a time sensitive decision, placing him in Kingdom House whilst an alternative permanent placement could be arranged in Bradford, where his family resided and where he had lived his entire life.

Kingdom House was a newly established residential home and the inquest heard evidence to suggest that many of the care staff employed at Kingdom House had limited experience of caring for someone with complex behavioural needs such as Thomas’. Throughout his time at Kingdom House, Thomas’ family reported concerns around his physical health and mental wellbeing. The inquest heard evidence that Thomas often told family members that he was feeling unwell, however these concerns were often dismissed as attention seeking behaviour.

Although Thomas had limited verbal communication skills, he often used Makaton sign language and his own gestural vocabulary to communicate. The family and visiting healthcare professionals gave evidence at the inquest that they did not observe staff using Makaton to communicate with Thomas and that the family therefore had concerns as to the staff’s ability to communicate with and understand Thomas. The family raised concerns during the inquest that the care staff’s inadequate communication skills impacted upon their ability to determine whether and to what degree, Thomas was unwell.

On 29 January 2015, an out of hours GP was called to Kingdom House in order to assess Thomas as over the last two to three days Thomas had been experiencing a chesty cough, had vomited, and was feverish. The GP diagnosed Thomas with a chest infection, prescribed Thomas with antibiotics and told care staff to call back if they saw no improvement within the next two to three days.

Later that day, during a call with his mother, Thomas seemed to experience a period of acute illness which included difficulties in his breathing and a period of unresponsiveness. Thomas’ mother demanded that care staff call 999 and paramedics attended to assess him. Following their assessment, paramedics decided against bringing him to hospital as his condition had improved by the time they had arrived. The paramedics also provided “worsening” advice, namely that carers should seek further medical review if Thomas’ condition did not improve.

The inquest heard evidence concerning Thomas’ physical state during the period of 29th January to 1st February 2015. This evidence included that Thomas seemed very tired and subdued, was coughing, complained of a sore throat, had vomited and passed stool in his bed (something not usual for Thomas). Although care staff reported that during this period Thomas was at times boisterous and was seen playing with his space hopper, Thomas’ father stated that he visited Thomas on 31 January 2015 and described him as looking unwell, that he was breathing strangely and was off his food.

On the evening of 1st February 2015, a 111 call was made by care staff as Thomas had vomited and the carers wished to check whether they could provide Thomas with his medication should he regurgitate it. The out of hours GP who gave the telephone advice did not explore Thomas’ past history and gave advice solely relating to that discrete query.

In the early hours of 2nd February 2015, Thomas suffered a cardiac arrest brought upon by a chest infection and tragically died two days later in hospital.

The inquest heard expert evidence that suggested that Thomas’ illness was probably caused by a viral infection and that it would be difficult to conclude whether or not he would have survived had he been admitted to hospital prior to his collapse.

Having heard evidence over four weeks, and five years after Thomas’ death, the jury in Sheffield concluded that Thomas died of natural causes. Prior to the jury being asked to come to their conclusion, the Coroner ruled that Article 2 of the European Convention on Human Rights (“Article 2” or the Right to Life) was not engaged and, in light of the expert evidence, that it would be unsafe to allow the jury to consider a conclusion involving neglect.

Following the conclusion, Paula Rawnsley, Thomas’ mother, said:

“Thomas was a beautiful, loving, compassionate and most of all mischievous little boy. He enjoyed spending time with his family and was loved like only a youngest brother to three big sisters can be. Thomas was a very much loved son, brother and uncle. When he was moved to Sheffield to a ‘specialist service’ run by Lifeways, this was against his and our wishes. Thomas’ physical and mental health declined rapidly and his family screamed out for help. Six months later he was dead. It is coming up to six years since Thomas died. We trusted in the coronial process however the inquest wasn’t able to examine any of the wider failings in care, the abuse he suffered, the lack of trauma support or why Thomas couldn’t live in his local community. It simply looked at the last five days of his life. I have found the process extremely distressing especially as it continued during a pandemic and during a national lockdown. The jury were instructed that the only finding they could reach was that Thomas died from natural causes. We are left wondering how it can be natural for a fit and healthy 20 year old to die from a chest infection.”

Sebastian Del Monte of Hodge Jones & Allen, acting on behalf of Thomas’ family, added:

“Thomas’ death is yet another example of how individuals with learning disabilities are failed in a health and care system ill-equipped to assist adults with complex care needs. We were in the midst of a national care crisis even before the present pandemic. The fact that we do not hold privately run care homes to the same standard as prisons or hospitals – where Article 2 is always engaged – is deeply concerning to me. The jury’s conclusion is not a vindication of the overall care afforded to Thomas. We have heard evidence to suggest that Thomas had been failed by authorities throughout his short life and although an inquest’s role is not the same as that of a public inquiry, it is a tragedy that lessons will not be learned from Thomas’ death almost as much as it is a tragedy for Thomas’ family.”

Deborah Coles, Director of INQUEST a charity that supports bereaved families including Thomas’ family, said: “Thomas’ death is being dismissed as ‘natural causes’ is shocking when the family had raised a series of safeguarding concerns and that staff responsible for his care lacked training.. Not to mention the many unanswered questions about the poor history of care and failings that were not allowed to be a part of the inquest.

Paula fought for her son in life and the system failed him. It has failed this family again by not delivering the scrutiny needed. Currently, inquest and investigation systems are failing to consistently and effectively shine a light on issues leading to the widespread premature and unexpected deaths of people with learning disabilities.

We need clearer guidance for coroners on when Article 2 can be engaged in these cases, to enable a more in-depth inquest, alongside decent investigations with the involvement of bereaved families, in order to build national oversight and encourage much needed policy and cultural change.”

Note regarding Article 2 and Inquests

Article 2 imposes a heightened duty on the state to investigate the wider circumstances that may have led to the death of anyone under the state’s care and control. It allows a jury at an inquest to consider what “possibly” caused a death rather than what “probably” caused a death (i.e. a lesser causative threshold is required when Article 2 is engaged).

Although the inquest in Thomas’ case had previously been deemed to engage Article 2, after the evidence had concluded the Assistant Coroner considered submissions made on behalf of Bradford Metropolitan District Council, Lifeways, Yorkshire Ambulance Service and the various GPs involved with Thomas’ care, that the investigative duty imposed by Article 2 of the European Convention on Human Rights (“Article 2”) was not engaged. These submissions broadly followed the case of R (Maguire) v HM Senior Coroner for Blackpool and Fylde [2020] EWCA Civ 738 where the Court of Appeal determined that the fact that the deceased had been placed in a private care home by the Court of Protection is not in and of itself sufficient to engage Article 2 (and thus trigger the wider investigation). It must either be arguable that the death arose from a situation of danger created by the state or from a systemic failure by the state in the provision of services where the authorities knew or ought to have known of the risk and failed to take measures to prevent that risk.

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