Lugh Baker · Prevention of Future Deaths report

On 13/3/23, I concluded an inquest into the death of Lugh Baker
.
The medical cause of death was recorded as:
1a) Unascertained
1b)
1c)
II)

I recorded an Open Conclusion.

Lugh was a 24-year-old man with a diagnosis of Angelman’s syndrome. He suffered with epileptic seizures for which he was prescribed medication, and he had difficulty swallowing. At the time of his death, he was a resident at Rosewood House in Launceston which provided supported living for individuals with physical and/or mental disadvantages.

On 21/4/21, he was given prescribed medication with a chocolate milkshake at about 20:00. He was checked upon subsequently before being found unresponsive at about 23:30. CPR was initiated during the course of which an unsealed, partly-consumed chocolate bar was seen under or near his bed.

Lugh had a care plan that mandated he should not eat unsupervised and should eat sitting up. It is not known how the chocolate bar came to be found where it was. It is further not known if Lugh had been eating it immediately prior to his death.

Lugh could not be resuscitated. A post-mortem examination did not reveal evidence of airway obstruction. The evidence did not further or fully explain the means whereby the cause of death arose.

i) I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh. I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form.

ii) Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident’s Care Plan to be reviewed after admission.

iii) Concern was also raised about what steps will be taken, and when, where a new resident with an unusual presentation is admitted. In this case, Lugh had a diagnosis of Angelman’s syndrome with which staff were unfamiliar. Again, I asked to see a policy document setting out what training or other steps will now be taken in such circumstances and by when.