A man whose health condition meant he was only supposed to be given mashed food and thickened drinks was ‘unlawfully killed’ when his support worker took him to a pub for a burger, causing him to choke to death.
An inquest heard that despite expert guidance making it clear solid foods were a risk to the life of Tony Wilkinson, support workers often provided him with unsuitable meals.
Stars Social Support Limited, a private company which specialises in providing care packages for adults with learning disabilities and physical disabilities, had been commissioned by Barnsley Metropolitan Borough Council to provide care services to Mr Wilkinson since 2014.
The 57-year-old had a genetic condition known as Fragile X syndrome, causing intellectual disability and behavioural and learning challenges.
Support was initially provided through a mix of Mr Wilkinson attending at a day care centre and staff visiting his shared accommodation. However, with his condition worsening and following a choking incident in February 2018, Stars staff were then required to provide 24-hour care and supervision.
A speech and language therapy assessment established Mr Wilkinson was unable to manage his own eating, drinking and swallowing needs, and warned that he faced the very real risk of choking, and death, should he not be provided with mashable food and thickened drinks.
But an inquest at Sheffield Coroner’s Court this week heard that despite this, Stars failed to ensure staff followed a clear care plan.
He was twice taken out by a support worker and given unsuitable meals, including fish, chips and mushy peas at the seaside and the trip to a pub at Manchester Airport, where his support worker ordered him a Bronx burger, which he choked on.
An inquest jury concluded that Stars had failed to provide safe care and did not have a robust procedure in place to implement the expert guidance over Mr Wilkinson’s food intake.
Jurors also concluded that support plans and risk assessments were not suitable to Mr Wilkinson’s needs, advice was not adequately communicated to staff, and that care being provided was not reviewed by managers.
Coroner Abigail Combes advised the jury they could conclude ‘unlawful killing’ if they considered the case to meet the test for either corporate manslaughter or gross negligence manslaughter.
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Inquest highlighted ‘complete lack of organisation and communication over care’
Hudgell Solicitors represented the sisters of Mr Wilkinson, June Mcdonald and Linda Swallow, and says the inquest highlighted ‘a shocking lack of organisation and communication’ which led to ‘inconsistent and inappropriate care which endangered life’.
Hudgells said: “Some of the evidence presented at this inquest was truly shocking as it painted a picture of a complete lack of organisation and communication which led to no clarity or consistency to the care provided to Mr Wilkinson.
“Evidence was provided by a support worker that all staff were confused as to what foods Mr Wilkinson could and couldn’t eat. Evidence was also given that he had access to cupboards and the fridge and to the food of other residents at his shared accommodation.
“The inquest heard that communication logs kept by staff indicated that Mr Wilkinson was provided with food that was outside of the guidance following his assessment. The lack of clarity and consistency over his care ultimately proved life-costing.
“The week before his death he was taken to Cleethorpes by a support worker with others, a trip that had not been risk assessed and which the Stars manager said should never have happened, and he was given fish, chips and mushy peas.
“Also, following his tragic death, support plans and risk assessments which were found at Mr Wilkinson’s home were more than three years out of date.”
Sisters say care provider was ‘woefully inadequate to care for vulnerable people’
On the day Mr Wilkinson choked and died, in April 2018, he was taken to a pub at Manchester Airport by a non-regular support worker.
Mr Wilkinson began choking and collapsed inside the pub toilets. Paramedics took him to hospital A&E where he died as a result of a foreign body airway obstruction, having suffered a cardiac arrest.
Mr Wilkinson’s sisters issued a joint statement following the inquest, in which they said: “It has been really hard for us to sit and listen to the evidence and hear so many people and organisations try and pass the buck in terms of responsibility. This was our brother’s life and yet nobody wanted to be accountable.
“In our minds, Stars proved themselves to be woefully inadequate when it comes to providing care for vulnerable people with complex needs such as our brother. A care provider of any quality would have ensured that all members of staff were aware of his needs and the best way to care for him with professionalism, empathy and understanding.
“The untimely death of our brother was preventable and avoidable and a jury has now found it to have been unlawful. Had this company acted in the way it should have, our brother would still be with us today.
“We cannot stress enough how terrified Tony would have been when alone with strangers at hospital. Instead of the wonderful memories we had of him, how loving and happy he was, we are now left with the images of him lying in mortuary. All of this has greatly impacted our mental health and our brother deserved so much better.
“Hopefully lessons are learned from all involved. The word care is used to describe services provided, but it is not accurate as true care is not what is given. That goes from local authorities selecting these companies and then washing their hands of responsibility when things go wrong, to the providers themselves.
“We would like to express our gratitude to Hudgell Solicitors for taking on our case and their continued support throughout. Furthermore, we are also thankful to John Hobson from Doughty Street Chambers for representing us so well at the inquest.”
