South Yorkshire man only allowed mashed foods “unlawfully killed” after choking on burger at Manchester Airport pub
A vulnerable Barnsley man was unlawfully killed when his support worker took him to the pub for a burger and he choked, an inquest rules this week.
Tony Wilkinson, 57, had a genetic condition known as Fragile X syndrome, causing intellectual disability and behavioural and learning challenges.
An inquest heard that despite expert guidance making it clear solid foods were a risk to the life of Mr Wilkinson, support workers often provided him with unsuitable meals.
This even included being taken for fish, chips and mushy peas at the seaside a week before his death when taken for a meal at a Manchester Airport pub.
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.
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.
This was despite the company’s own policies stating that ‘robust procedures should be in place to ensure all staff are aware when service users require modified diet or fluid consistency and this must be communicated to all staff involved in the care of the service user.’
He was twice taken out by a support worker and given solid 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.
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 Wythenshawe Hospital A&E where he was taken to theatre to remove pieces of burger from his lung.
He died as a result of a foreign body airway obstruction, having suffered a cardiac arrest.
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.
Stars must now provide written evidence to the Coroner, within two weeks, of measures being taken to address the concerns raised, and ensure improvements are made to prevent similar incidents in the future.
Solicitor Simon Wilson, of Hudgell Solicitors, represents 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’.
Mr Wilkinson’s sisters say Stars was ‘woefully inadequate to care for vulnerable people’
Ms Mcdonald and Ms Swallow issued a joint statement following the inquest, in which they said:“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.
Stars Social Support is currently under review of the healthcare watchdog the Care Quality Commission (CQC) after a number of inspections raised concerns over the quality of care provided.
The latest inspection, carried out on August 27, 2020, found the services provided to be ‘inadequate’, ‘not safe’ and ‘not always well led’.
Wendy Lowder, Executive Director for Adults and Communities, said: “The Council wishes to pass its condolences to Mr Wilkinson’s family and to reassure them and the public that our continued priority is ensuring the safety and well-being of our residents. We’ll continue to regularly review our adult social care processes to make sure they deliver high-quality care and support.
“We are continuing to engage with the Care Quality Commission and the Coroner regarding the inquest into Mr Wilkinson’s death.
“Stars Social Support is a non-contracted provider, meaning they’re not contracted as part of the Council’s framework agreement.
“However, we have actively reviewed Stars’ provision in the borough and have contacted all existing service users who are supported by Stars and will support any individual who wishes to change their care provider.”