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Jury blames inadequate care for death of man with learning disability

The jury at an inquest into the death at a residential care home of a man with autism and a learning disability today concluded that his death was contributed to by neglect, specifically inadequate care from inexperienced staff who did not know how to deal with an emergency.

64-year-old Anthony Dawson died in May 2015 from a gastric hemorrhage caused by an underlying gastric ulcer while living at Ashmount care home in Epsom, Surrey, a seven-bedroom care home, run by Surrey and Borders NHS Partnership Trust and registered under the Care Quality Commission.

Despite concerns about his health voiced by his family, staff at the care home did not call a GP promptly for help or pass on critical information about Anthony’s condition.

The jury also highlighted that despite funding, essential ongoing 1-1 care was not provided to Anthony, nor was his care plan adhered to. He was also deprived of basic health care.

Medical evidence showed that for 13 years, Anthony had not received the regulation blood tests mandatory for residents prescribed the antipsychotic drug Olanzapine. He had also missed outpatient screenings and had not received basic medical care such as dentist appointments.

Anthony had Pica – a disorder known to pose serious health risks – which meant he regularly picked up and ate non-nutritious items, particularly cigarette ends that he found on site, of which the staff were fully aware. Anthony was regularly prescribed the maximum daily dose of ibuprofen, not recommended for people at risk of ulcers.

Julia Dawson said that her brother, who was diagnosed with regressive autism aged two-and-a-half and had lived in various forms of institutional care since aged 10, had his right to healthcare taken away from him and was left to get ill and die. She also said that Anthony was regularly left to wander around the campus around the home unsupervised and was often locked out.

“Anthony was a gentle, popular man who was simply treated by the NHS as a number and casually abandoned to his fate. Our trust was betrayed. We believed that Anthony would be protected and his health prioritised while he lived under the care of an NHS trust.”

“I promised my mother I would get my brother out of Ashmount but I could not deliver that promise. An entrenched culture of neglect had taken hold and nothing was done to prevent this avoidable catastrophe. Tragically, someone had to die before any action was taken.”

Ms Dawson raised serious concerns about Anthony’s health as he clearly became increasingly unkempt and unwell, but her concerns were not listened to. Anthony died after collapsing at the home and vomiting black blood. Staff were unable to resuscitate him.

The assistant coroner for Surrey Darren Stewart said that under Regulation 28, he would issue a Preventing Future Deaths in relation to review of the Trust’s procedures in an emergency.

Ashmount House is on the site of the former St Ebba’s hospital, a long stay hospital for people with a learning disability closed down 10 years ago in favour of community based living. NHS England has commissioned an independent investigation into Anthony’s death, which will conclude in 2018.

Nancy Collins represented the Dawson family at the inquest and will pursue a civil claim against the Trust.

“It is only through the dogged determination of Julia to get the bottom of the circumstances surrounding her brother’s death that the appalling lack of care afforded to him has been revealed. It is tragic and wholly unacceptable that families continue to have to fight to ensure that loved ones with learning disabilities are provided with the care and support they need,” she said.

Jan Tregelles, chief executive of Mencap and Vivien Cooper, CEO of The Challenging Behaviour Foundation said:

“Anthony Dawson lived and died in an institution located in the grounds of a former long-stay hospital setting. Despite all the efforts of his family to try and get his needs properly met, they were side-lined, their concerns not acted upon, his health needs were neglected and Anthony died an untimely death that could have been prevented.

“Anthony needed continual 1-1 support yet was often left to walk the grounds alone. He lacked basic health checks and was on four medications for mental health conditions for which he had no diagnosis. The commissioner of his service and the Care Quality Commission who inspected it failed to take action. He spent his life in the same place shut away from the world, despite the efforts of his family to change this.

“The Government is clear that “Hospitals are not homes” and Anthony should not have been shut away from the community. Its own research has highlighted the premature and preventable deaths of 1,200 people with a learning disability every year. Yet despite two NHS England programmes – one to transform care and one to reduce premature mortality – Anthony’s care was not transformed and he continued to live in a hospital setting, dying there aged 64.

“It is taking too long for the Government, the NHS, the Care Quality Commission and local authorities to deliver on their promises to ensure people with a learning disability get the right support, within their communities and with access to proper healthcare. There is no accountability for this painfully slow progress. For people with a learning disability and their families, it is a matter of life and death that cannot be ignored.”

For further information, please contact:

Kerry Jack or Nicola Pearson at Black Letter Communications or
020 3567 1208

Notes for Editors

The inquest ran for 12 days at Woking Coroner’s Court in front of assistant coroner for Surrey Mr Darren Stewart.

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About Mencap

There are 1.4 million people with a learning disability in the UK. Mencap works to support people with a learning disability, their families and carers by fighting to change laws, improve services and access to education, employment and leisure facilities. Mencap supports thousands of people with a learning disability to live their lives the way they want.

For advice and information about learning disability and Mencap services in your area, contact Mencap Direct on 0808 808 1111 (9am-5pm, Monday-Friday) or email

What is a learning disability?
A learning disability is a reduced intellectual ability which can cause problems with everyday tasks – for example shopping and cooking, or travelling to new places – which affects someone for their whole life.

People with a learning disability can take longer to learn new things and may need support to develop new skills, understand difficult information and engage with other people. The level of support someone needs is different with every individual. For example, someone with a severe learning disability might need much more support with daily tasks than someone with a mild learning disability.

Learning disability is NOT a mental illness or a learning difficulty. Very often the term ‘learning difficulty’ is wrongly used interchangeably with ‘learning disability’.

About The Challenging Behaviour Foundation

The Challenging Behaviour Foundation provides information, support and training around challenging behaviour associated with severe learning disabilities, and leads the ‘Challenging Behaviour National Strategy Group’ which seeks to influence policy and practice nationally on behalf of individuals who challenge and their families.

The Challenging Behaviour Foundation was founded in 1997 by Vivien Cooper, parent of a son with severe learning disabilities and behaviour described as challenging. Today the Challenging Behaviour Foundation is in regular contact with over 5000 families and professionals across the UK. There are an estimated 30,000 individuals in England with severe learning disabilities and behaviour described as challenging.