A coroner has said a 'missed opportunity' to increase the care of a severely disabled man partly contributed to his horrific death. Matthew Dale, previously of Warrington, died at the Vancouver House care home in Netherley, Liverpool, on December 27, 2020 after choking on an incontinence pad.
The 43-year-old had complex needs including significant learning disabilities, autism, visual impairment and bi-polar affective disorder, CheshireLive reports. He moved to Vancouver House in February 2011.
He had a previous history of swallowing non-food items, which happened four times in 2010 before he moved to the care home. There were two incidents of Matthew trying to ingest a piece of his incontinence pad shortly before his death - December 15 and December 26 2020.
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It happened again on December 27 and staff members found him choking. They attempted to dislodge the item from his throat with back slaps before Matthew soiled himself at which point staff 'turned to attending to his personal needs rather than the serious choking risk'.
He was taken to his room where they tried to dislodge it with abdominal thrusts but these also failed. He fell unconscious and was given CPR by both staff and paramedics but he could not be revived.
An inquest into his death, held on January 25 by Liverpool and Wirral coroner Kate Ainge, concluded that he had died as a result of 'misadventure'. But Ms Ainge added that it was 'in part contributed to by a missed opportunity to increase supervision to meet Matthew's needs'.
Multiple agencies had been involved in Matthew's care over the years and the coroner believed a breakdown in communication caused confusion over the level of supervision he required. Matthew initially received one-to-one care at Vancouver House between 8am and 8pm each day. It was funded by Warrington Council from 2011 until September 2018 and then by Liverpool CCG.
At the time he moved in, the care home's managers were aware of Matthew's risk of trying to swallow non-food items. In September 2011, they noted the risk had 'significantly reduced' after he settled.
But the care home's owners changed along with the management during the period of Matthew's stay. According to a prevention of future deaths report by Ms Ainge, the new managers 'were not aware of any risks of Matthew ingesting non-food'.
Health commissioners believed he needed one to one care between 8am and 8pm along with ongoing supervision during the waking hours outside that timeframe. But Ms Ainge reports that Vancouver House staff believed they were to provide him with one to one care from 8am to 8pm and then supervision when eating along with 'hourly observations'.
Ms Ainge also said the two times Matthew tried to swallow part of his incontinence pad on December 15 and December 26 were not properly escalated.
She said: "Whilst some staff had an awareness of Matthews risk to put non-food items in his mouth, others did not. Whilst recorded in Matthews daily notes, these concerns were not properly escalated to senior management and this provided a missed opportunity for Matthew to have increased supervision levels on an urgent basis and until a multidisciplinary team meeting could be confirmed to reassess and consider his needs.
"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."
While concluding that the confusion surrounding the care that Matthew was supposed to receive did not amount to 'neglect', Ms Ainge said it did contribute to the cause of his death.
In her prevention of future deaths report, Ms Ainge wrote: "It became clear in the inquest that the commission, funding, assessment and provision of care needs is a complex process, particularly as in Matthew's case where there are multiple agencies involved due to his own complex and multifaceted needs.
"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 Matthews care and that which should have been in place and that which was in place."
A spokesperson for Priory Group, which ran Vancouver House at the time of Matthew's death and when it closed in September 2021, said: “We listened carefully to the Coroner at the inquest, and noted her comments at its conclusion.
"Our thoughts are with Matthew’s friends and family. Our focus is on ensuring we have collaborative relationships with all our commissioners, to ensure all residents’ requirements are met.”
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