A coroner has raised concerns about a Surrey care home after a man died from choking while suffering from undiagnosed oesophageal cancer.
Assistant Coroner for Surrey, Caroline Topping, is considering whether to issue a future deaths report, after Daniel, 41, died after choking, with undiagnosed throat cancer later found to have completely clocked his oesophagus.
Daniel passed away in hospital in September 2023 after being taken there from Ballater House Care Home in Chipstead, Surrey.
Topping noted that Daniel’s learning disabilities and Down Syndrome also contributed to his death, but claimed the care he received at Ballater house did not.
However, the inquest raised questions about the systems in place at the home. The evening before he died, Daniel, who had type 1 diabetes, experienced a hypoglycaemic episode. The coroner said he recovered but was left alone without his blood sugar being checked.
Later that evening, he was found vomiting and refusing to sit up.
The inquest also heard Daniel had been repeatedly throwing up in the months before his death, but his family were never told about this.
Originally from South London, Daniel was described as a ‘gentle soul’ by his family. His cousin Sarah became involved in his care and she said the family believed he was happy and healthy at the care home.
‘Daniel’s death came completely out of the blue,’ Sarah said. ‘We believed he was fit, healthy and happy at his care home, and had never been given any reason to think otherwise.
‘Within 24 hours, we went from a normal evening to being told his life support had to be withdrawn. We are still struggling to come to terms with what happened.
‘We feel the information we received from the care home did not appear to match what we later learned at hospital, where we were told Daniel had suffered a severe lack of oxygen to the brain. We were left with no clear understanding of how this could have happened while he was in a setting where nursing support should have been readily available.’
Sarah Westoby, a human rights solicitor at Leigh Day – the firm representing the family – said the inquest highlighted the difficulties faced by people who can’t communicate their care needs themselves.
She said: ‘The circumstances of Daniel’s death appear to show a lack of understanding of how to care for people with learning disabilities, who are unable to communicate their needs and entirely reliant on care staff to understand and meet their needs.’
The inquest heard that some care home staff believed Daniel was ‘putting it on’ when he experienced recurrent vomiting.
Westoby said the home had also failed to call an ambulance, contact his GP or inform his family when Daniel suffered a serious health crisis in the month before his death.
While the coroner has not yet confirmed whether to issue a prevention of future deaths report, Daniel’s family said they hoped their experience would lead to a better care for people with learning disabilities.
‘Our hope is that Daniel’s case raises awareness of the challenges faced by some of the most vulnerable people in society, and encourages greater accountability, better care and earlier intervention for those who struggle to make their voices heard.’
Image: Sasun Bughdaryan/UnSplash
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