20 Jul 2021 Ben Buster KING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 20 Failure to address weight gain and set weight-loss goals in multidisciplinary reviews View source Failure to contact the respiratory on-call consultant on repeat presentation View source Failure to implement substantive safety changes in residential care homes View source Reduction of dietician-led staff training View source Failure of internal investigations to capture identified care concerns View source Failure to provide timely responses to care staff seeking clarification of discharge and escalation plans View source Failure of staff to follow basic dietary advice and guidance View source Failure to notify the respiratory team of emergency department attendances View source Failure to carry out one-to-one observations in accordance with policy View source Failure of the care recording system to support accessible and complete food and fluid intake records View source Failure to record pertinent medication history on discharge documentation View source Failure to hold multidisciplinary team meetings at required intervals View source Reliance on outdated weight measurements in multidisciplinary reviews View source Failure of the care software system to provide accessible and usable policies and documents View source Failure to provide clear, accurate and complete discharge advice View source Failure to communicate prior emergency department attendance to the respiratory consultant View source Failure of staff to complete important care records View source Failure to ensure regular exercise provision View source Unavailability of CCTV in residential care homes View source Failure to document risk-benefit analysis for pertinent respiratory-affecting medication View source See 17 more concerns
Responses linked to these concerns
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AI-generated summary
Ben Buster KING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to address weight gain and set weight-loss goals in multidisciplinary reviews
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the respiratory on-call consultant on repeat presentation
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement substantive safety changes in residential care homes
Wider context from the report “9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest
10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Reduction of dietician-led staff training
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to capture identified care concerns
Wider context from the report “9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest
10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely responses to care staff seeking clarification of discharge and escalation plans
Wider context from the report “4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate”. On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.”
On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2”
On 12 July 2020 the Discharge Plan provided “Home”.
The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop.
Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response . Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow basic dietary advice and guidance
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the respiratory team of emergency department attendances
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out one-to-one observations in accordance with policy
Wider context from the report “2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the care recording system to support accessible and complete food and fluid intake records
Wider context from the report “8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL.
Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record pertinent medication history on discharge documentation
Wider context from the report “5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to hold multidisciplinary team meetings at required intervals
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on outdated weight measurements in multidisciplinary reviews
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the care software system to provide accessible and usable policies and documents
Wider context from the report “8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL.
Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided , some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear, accurate and complete discharge advice
Wider context from the report “4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” . On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.”
On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2”
On 12 July 2020 the Discharge Plan provided “Home”.
The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop.
Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate prior emergency department attendance to the respiratory consultant
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to complete important care records
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure regular exercise provision
Wider context from the report “6. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CCTV in residential care homes
Wider context from the report “2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jeesal Residential Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document risk-benefit analysis for pertinent respiratory-affecting medication
Wider context from the report “5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis . Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and improve the Pandora information system through a staff user group.
Verbatim wording from the response “6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospital systems and processes are not considered generally relevant to residential services, so sweeping changes are not necessarily warranted.
Verbatim wording from the response “While lessons can be learned from any enquiry, it does not necessarily follow that sweeping changes should be made in residential services unless those changes emanated from a review of residential services elsewhere. In which case there would undoubtedly be valuable lessons to learn, the people that are supported, the staff the management and the collaborative working in our services demonstrate that we are well ahead of the workings of a hospital setting. Hospital systems and processes are often not relevant to the way services are delivered for our residents.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CCTV is considered inappropriate in residential homes because it would intrude on residents’ rights and liberties.
Verbatim wording from the response “2. CCTV is often used in hospital settings, though only in shared public areas. CCTV would be totally inappropriate in the residential homes that we manage. It could be considered an intrusion in the rights and liberties of residents, who consider the house as their home.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A sports instructor is not considered necessary because residents are encouraged to use community facilities and activities.
Verbatim wording from the response “7. Because our primary focus is community participation, we do not employ a Sports instructor. We encourage, wherever possible, for our residents to access community facilities including local gyms, swimming pools and a wide range of community activities. Each service user has a written care plan, this is developed with the individual and takes account of his / her preferences, interests, lies and dislikes, it will also involve input from external professionals.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A paper-based care system is considered detrimental because it would undermine remote monitoring, statistical analysis and a whole-system approach.
Verbatim wording from the response “We note the suggestion by the Dietician to have a paper-based system. We am resistant to this as this will undermine my ability and the ability of GAT and external colleagues to monitor remotely. I consider a two-system approach to be detrimental when trying to achieve a whole system approach to care and support. Unlike a hospital where the patients are in one place, our residential services are spread across the county and as such, while physical attendance at a home is important, so too is remote access. In addition, the Pandora system allows us to carry out statistical analysis and monitor trends.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The internal investigation was suspended because continuing it could compromise the police investigation.
Verbatim wording from the response “11. The coroner is correct the investigation did not capture the concerns raised in the inquest. However, the investigation was halted due to the matter becoming a Police Investigation and as such common practice is any internal investigation is suspended to ensure it does not compromise the Police enquiry. I am satisfied that if we had been allowed to proceed all of the issues would have been identified by the investigating officers.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations