Enid Baber · Prevention of Future Deaths report

On 27th June 2019 an inquest was opened touching upon the death of Enid Baber Dec’d, who was aged 85 years at the time of her death on 28th April 2019. The investigation concluded at an inquest which I heard on 27th and 28th November 2019. The conclusion was the short form conclusion of “Accidental death”.

Mrs Baber was cognitively impaired at the time she died which led to her making a decision to run a bath late at night or in the early hours of the morning. This was entirely out of character for her and was an irrational decision, given that she had had a thorough wash on the 27th April 2019. Mrs Baber either got into the bath backwards or fell backwards into the bath, following which she died suddenly.

Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision.

I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty. They have not received specific training on this difficult assessment process.

In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to do so.

Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home.