A coroner has warned that more vulnerable people could be at risk after finding "missed opportunities" in the care of a disabled man who choked to death.
Matthew Dale, who had severe learning difficulties and autism, choked to death on his own incontinence pad at Vancouver House on Vancouver Road, Netherley, on the night of December 27, 2020. The 43-year-old had been left alone in the dining area, during which time he was able to ingest a piece of the pad.
His inquest last month revealed there had been a "breakdown in communication" between Liverpool CCG and care home managers, which led to Matthew not receiving the constant one-to-one care he needed during waking hours.
READ MORE: Disabled man who choked on incontinence pad was 'much-loved' son
The CCG had provided funding for daily one-to-one care for Matthew between 8am and 8pm on the understanding that this was on top of the care already provided by Vancouver House. But Vancouver House managers believed this was the only care they were supposed to provide, and Matthew was given only hourly check-ups outside of these hours.
Coroner Kate Ainge has now written to the Department of Health warning "there is a risk that future deaths could occur" if changes are not made.
She said: "In this case it has been established that there was a confusion over the care in how it was funded and expected to be provided, compared to that which was understood to be funded and actually provided on the ground to Matthew.
"The confusion appears to have arisen over the understanding of a number of care terms and the use of them, which has resulted in two commissioning agencies and an agency providing the care having differing views about Matthew's care, and that which should have been in place and that which was in place."
A previous hearing found opportunities had been missed to increase Matthew's supervision at Vancouver House in the days before his death, as he had been seen attempting to eat inedible objects on on December 15 and December 26 2020. However, these incidents were not properly escalated.
The coroner said: "Had the incidents on the 15 and 26 December have been properly escalated, Matthew would have been on 15 minute observations, he was in fact on hourly observations and when unsupervised Matthew placed a piece of his incontinence in his mouth and swallowed it. As a result, the piece of pad expanded with the saliva and became trapped in his airway."
She handed down a conclusion of death by misadventure, contribute to by a missed opportunity to increase supervision to meet Matthew's needs.
READ NEXT
EncroChat drug runner 'Ladbrookes' given away when contact calls him 'Kurt'
Live updates M62 still closed through rush hour after lorry fire
A Place in the Sun's Jasmine Harman supported over 'tremendously sad news'
Woman shouts in dock as she's jailed for cathedral arson attack
