Second inquest into death of Peter Seaby concludes care home failings contributed to death of resident

24 February 2023: The second Inquest into Peter Seaby, a man with Down’s Syndrome who died at The Oaks and Woodcroft Care Home, Norfolk, in May 2018, concluded today at Norfolk Coroner’s Court. The Inquest was heard before Area Coroner Jacqueline Lake who delivered a narrative conclusion. The Coroner found that Peter Seaby’s care plan was not followed; he was not given food in a way that would minimise the risk of aspiration, and he was not supervised on a 1:1 basis, as required. The Coroner will be requesting a Prevention of Future Deaths report from the Priory Group.

Today’s conclusion reverses the findings of an inquest held in August 2021 that was dismissed last year after a Judicial Review ruled that not all factors had been initially considered.

Peter died aged 63 at the care home where he had been a resident for almost six months. He had previously been cared for by his sister, Karen Seaby, but in November 2017 was moved into Oaks and Woodcroft Care Home for a period of ‘respite.’ However, according to his family, Peter became a permanent resident explicitly against their wishes.

The day before his death, 21 May 2018, Peter started experiencing difficulties with swallowing and keeping food and water down after his lunchtime meal. Peter was initially taken to a GP, but his condition deteriorated after his visit. Staff at the care home did not adequately escalate their response to Peter’s condition, and once medical support was sought, the care home called 111 instead of 999. On the evening of 21st May 2018, Peter was taken to Norfolk and Norwich Hospital where he sadly died of aspiration pneumonia on 22nd May 2018.

Peter had significant swallowing difficulties and was at risk of choking on his food. The Norfolk Community Health and Care Trust had devised a Speech and Language Therapy (SALT) care plan for him, which was in place at the care home. It stated that his food should be a fork-mashed diet, comprised of food with a “soft, moist, mashed consistency.”

The care plan noted that if its recommendations were not followed, Peter’s risk of asphyxiation was ‘high’ and his risk of aspiration ‘moderate.’ However, despite the plan, the post-mortem revealed that a large piece of carrot, approximately 2cm in diameter, was lodged in Peter’s throat.

In the narrative conclusion, it was stated that categorical failings in the care home system led to Peter Seaby’s death. He was not provided with food in a way that would minimise aspiration during his time at the care home, and he was not supervised on a 1:1 basis. The Coroner stated that Peter’s death may been prevented with adequate supervision and checks on the food he was served. A Prevention of Future Death Report has been requested by Area Coroner Jacqueline Lake from the priory group in light of the outcome.

Mick Seaby, Peter’s brother, said: “We were really disappointed with the conclusion of the last inquest. We felt like this didn’t answer all our questions and we didn’t get the conclusion that we wanted or felt like Peter deserved. Although the idea of a second inquest was daunting, we felt like we owed it to Peter to have a second inquest, to get justice for him. We loved our brother Peter dearly, he was a lovely, fun, cheeky chap and Karen spent her whole life caring for him. We hope that lessons are learnt by both Norfolk County Council and the Priory Group to avoid anything like this from happening to another vulnerable individual like Peter.”

Nina Ali, Partner at Hodge Jones & Allen, representing Peter’s family, said: “Peter’s family have shown great strength following the last inquest, to fight for a judicial review and attend a second inquest. It has been a long and, at times, difficult process for them. I am pleased the Coroner has concluded that failings at the care home may have led to Peter’s death and that he received inadequate supervision. Peter’s family now has the justice they deserve. We hope the relevant organisations learn lessons from this tragic case – and I welcome the order from the Coroner for a Prevention of Future Deaths report to be prepared.”