The tragic death of a disabled man who choked on his own incontinence pad after being left alone in the care home where he lived amounted to gross negligence and a breach of human rights, his family's counsel said.
Matthew Dale, who had severe learning difficulties and autism, was found dead in the dining area of Vancouver House on Vancouver Road, Netherley, at around 11.50pm on December 27 2020.
He had been living at the home 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 give the vulnerable 43-year-old.
READ MORE: Disabled man choked to death on incontinence pad at 'inadequate' care home
As a result, Mr Dale did not receive the necessary one-to-one care he required during all waking hours for the whole nine years he resided at Vancouver House. Instead, he was given only hourly checks between 8pm and 8am.
His inquest previously heard Mr Dale would often put inedible objects into his mouth, including his own incontinence pads. To prevent this, his parents would give him draw-string belts and dress him in a back-to-front onesie to prevent him taking off the pads - however, no such preventions were in place at Vancouver House.
Mr Richard Copnall, representing Mr Dale's family, said the failures in Mr Dale's care amounted to negligence, and that both the care home and commissioners had breached Article 2 of the European Convention on Human Rights - the right to life - both operationally and systematically.
He said: "There are two potential failures which are capable of amounting to negligence. The first is the absence of any system to prevent Matthew having access to his pad, such as the system used by his parents when he was living with them. The second is that Matthew was left alone, unsupervised at the time he put the fatal pad in his mouth.
"Matthew was a man with a profound disability which made him incapable of keeping himself safe. He was in many ways more vulnerable than a child because he had a child's limitations with an adult's ability to tear bits off his pad and put them in his mouth. It's a combination of those two things that made him particularly at risk."
He said the risk to Mr Dale should have been noticed by the staff, as there had been two "near misses" of Mr Dale putting inedible objects into his mouth in the 12 days before he died.
He also said: "There was a complete misunderstanding between the commissioners and care providers. The commissioners heard that Matthew required one-to-one care, they believed that's what their funding had secured and what Matthew was receiving. Whereas the hours of care that Matthew actually needed and the hours that were funded were two entirely different concepts."
He added: "Over nine years, many individuals from two commissioning groups and from the care providers have been involved. There have been multiple reviews and meetings and on all these occasions there has been a fundamental misunderstanding between what the comissioners think they are buying and what the providers think they are being paid to supply. It's simply not possible to describe that nine year history as mere individual negligence."
Miss Liz Wheeler, representing Integrated Care Systems, previously Liverpool CCG, said that Mr Dale was "undeniably vulnerable" but this alone was "not enough to engage Article 2".
She said: "We can see from the Deprivation of Liberty Safeguard (DOLS) reviews that the risks identified (to Matthew) were head banging, hand biting and cramming his mouth during meals. These are repeatedly identified. At no point during any of these reviews... has putting inedible objects in his mouth been identified. Insofar as the state has assumed any responsibilty to Matthew, that duty would apply to head banging , biting his hands, and cramming his mouth at meal times."
Mr Ed Pollard, representing the Priory Group, which ran Vancouver House before its closure in 2021, agreed with Miss Wheeler, adding: "There is a large area for (the coroner) to consider between anything that may be a failure and anything that amounts to gross neglect."
The inquest continues.
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