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Investigation and inquest
On 23 January 2025, I commenced an investigation into the death of Jake Daniel Taylor, aged 19 years.
The medical cause of death was unascertained although considered to be due to natural causes.
Jake died on 20 January 2025 in Kingston hospital after he suffered a cardiac arrest in his care home on 16 January.
Conclusion
Death due to natural causes, but the reason for the collapse could not be medically determined.
Circumstances of the death
The cause of the cardiac arrest could not be ascertained. Jake required 24 hour care, had global developmental delay, cerebral palsy and epilepsy and was at high risk of aspiration and choking. On the day of the arrest he was being cared for in accordance with his 1:1 needs, but when he collapsed there were delays in providing appropriate first aid, as necessary equipment including a defibrillator was not immediately available and chest compressions were not commenced until the arrival of the emergency responder, even though the staff present were first aid trained and had nursing qualifications.
A “do not attempt CPR” had been discussed variously between his family, carers, paediatrician (however he had now transitioned into adult services), but this had not been fully considered or implemented. There was no plan for the individualised first aid response that Jake required due to his body posture and known osteopenia.
Due to uncertainties of staff as to how to proceed, there were no beneficial interventions until the arrival of the London Ambulance Service, some 7 minutes after the 999 call was initiated, when all possible interventions were conducted. By this time Jake had sustained an unsurvivable hypoxic brain injury.
It could not be concluded if earlier interventions would have changed the outcome, but opportunities to do so were potentially lost.
Coroner’s concerns
No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
Information checked against the published report and official responses