Fosters supports bereaved mother of Ben King at inquest

Ben was a 32-year old man with Down’s syndrome and a severe learning disability, who had spent over two years at Cawston Park Hospital in Norfolk, where he was being held under the Mental Health Act. He also had obstructive sleep apnoea, a condition common in people with Down’s syndrome, which affects breathing during sleep but is not usually life threatening.

During the inquest evidence was heard concerning Ben’s treatment and the events leading up to his death, concluding that there were failures in the care he received.

Working with Jonathan Metzer of 1 Crown Office Row, Fosters’ Carl Rix represented Ben’s mother, Gina Egmore at Norfolk Coroner’s Court. Commenting at the conclusion of the inquest, Ms Egmore said: “Throughout the two weeks of the inquest I had to listen to and watch some truly harrowing evidence, including CCTV showing staff at Cawston Park twice striking my son and failing to raise the alarm when he went into cardiac arrest.

“I looked after Ben for the first 30 years of his life, and I expected that he would be properly cared for when he was transferred to Cawston Park. However, the evidence heard at the inquest suggests this clearly wasn’t the case. Whilst nothing can ever make up for the devastating loss of Ben, given the jury’s conclusion I can take some comfort from knowing that I managed to obtain justice for my son.”

Carl Rix of Fosters solicitors, commented: “Throughout the inquest process Gina has raised numerous concerns about the quality of care her son received at Cawston Park, and the jury’s findings certainly vindicate these. She has shown immense bravery in seeking justice over the last year, and it was a privilege to have represented her in this tragic case.”

Summary of inquest

Evidence was heard that Ben’s weight increased dramatically in the 14 months leading up to his death, from approximately 85 kg to approximately 106 kg. However, the Multi-Disciplinary Team at Cawston Park did not identify weight loss as a goal for Ben, dietary advice was not properly followed (with Ben continuing to be taken to fast food restaurants) and the number of physical activities he was offered dropped considerably. In the opinion of the expert witness, this led Ben to develop the life-threatening condition of obesity hypoventilation syndrome and that if had it not been for his weight gain, he would not have died.

In addition, Ben was taken to A&E on three separate occasions in mid-July 2020, as a result of low oxygen saturations and breathlessness, but was not admitted to general hospital any of these times. The expert witness stated that there was a failure to make the appropriate diagnosis.

On the morning of the 28th July 2020, staff recorded that Ben had oxygen saturations of 35%, far lower than the ordinary range of 95-100% in an ordinary healthy person. He was also displaying signs of abnormal breathing, drowsiness and at times, blueness to his lips and fingers. However, over the next 24 hours, the consultant and speciality doctor would both advise on more than one occasion against using oxygen or calling 999.

In the evening, Ben became agitated and was given promethazine as a sedative, in accordance with instructions to calm him. In the opinion of the expert, this led to a significant respiratory deterioration. However, the evidence was that over the course of the night Ben’s carers observed him only irregularly and did not offer assistance or raise the alarm when he fell backwards when trying to stand up, or when he stopped breathing. It is also understood that police are investigating a potential physical assault on Ben.

The inquest jury concluded that Ben “died due to inadequate weight management and failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine” and that there was a “failure to identify the seriousness of a life-threatening situation”. The Coroner has also made a Regulation 28 Report to prevent future deaths, which identifies 10 items of concern relating to Jeesal Akman Care Corporation Ltd (which ran Cawston Park) and six items of concern relating to Norfolk and Norwich University Hospital NHS Foundation Trust.

With two other contentious deaths also having taken place at Cawston Park Hospital since 2018, the hospital had been in special measures since 2019. It formally closed on 12th May 2021.

The Charity, INQUEST, who help support bereaved families covered this case. Lucy McKay from the charity, commented: “Ben was a man with multiple care needs, left to languish and decline, detained in a failing hospital for two years. Despite the love and commitment of his mother, they were let down by the very people who should have been specialists in keeping him healthy and safe. Particularly in his final moments, it appears staff lost sight of Ben’s humanity and their duty to protect him.

“Like far too many deaths of people with learning disabilities, Ben’s death was premature and preventable. It took place in a hospital which regulators knew was inadequate, where at least two other people had already died. National action on the provision and standard of care for people with learning disabilities is urgently needed and long overdue.”

Fosters Solicitors have extensive experience in representing families at inquests where they have lost loved ones in hospital settings. If you would like to find out more information about the services we can provide and how we might be able to support you, please contact us on 01603 620508.