By Victoria Mckeown
The mother of an autistic child has condemned the process and findings of an inquest which concluded in Sheffield on Wednesday that her son died of natural causes.
After sitting for nearly four weeks, the inquest concluded that the death of Thomas Rawnsley who died of an infection, should only be determined by looking at his last 5 days at a residential care home in Yorkshire. The mother strongly disputes the findings and wants the care home legally held to account for the death of her son.
Hodge Jones and Allen, one of the UK’s most progressive law firms renowned for its teeth for fighting injustice, is still closely examining the findings of the inquest.
The firm’s team of specialists which operates across a range of legal issues including Civil Liberties & Human Rights, Criminal Defence, Dispute Resolution, Employment Law and multiple other areas of law, are presently dissatisfied with the outcome of the inquest. The inquest places no duty on the residential care home to take care of those under its care, as is normally required of Article 2.An examination of all the background issues left out of the inquest may deserve examination.
Court Of Protection
In July 2014, Thomas Rawnsley, a vulnerable young man with Down Syndrome and Autism Spectrum disorder was placed by order of the Court of Protection in a residential care home in Sheffield, Kingdom House (operated by Lifeways).
Having previously been detained under the Mental Health Act at an Assessment and Treatment Unit in Bradford, he was out in care against the wishes of his family.
Due to the unit’s inability to cope with Thomas’ complex needs, the Court of Protection made a time sensitive decision, placing him in Kingdom House whilst an alternative permanent placement could be arranged in Bradford, where his family resided and where he had lived his entire life.
Kingdom House was a newly established residential home and the inquest heard evidence to suggest that many of the care staff employed at Kingdom House had limited experience of caring for someone with complex behavioural needs such as Thomas’. Throughout his time at Kingdom House, Thomas’ family reported concerns around his physical health and mental well being.
Sign Language
Thomas had limited verbal communication skills, and often used Makaton sign language and his own gestural vocabulary to communicate. The family and visiting healthcare professionals gave evidence at the inquest that they did not observe staff using Makaton to communicate with Thomas and that the family therefore had concerns as to the staff’s ability to communicate with and understand Thomas.
The family raised concerns during the inquest that the care staff’s inadequate communication skills impacted upon their ability to determine whether and to what degree, Thomas was unwell.
An inquest jury of seven women and two men concluded that Mr Rawnsley died of natural causes on the direction of Sheffield assistant coroner Abigail Combeshome, in Sheffield, after suffering from a chest infection.
Ms Combes told the jury that, despite listening to evidence since the beginning of September, natural causes was the only conclusion available for them to reach.
This followed a legal ruling she made on Tuesday which meant the jury was barred from considering the wider circumstances of Mr Rawnsley’s care, and had to focus on the immediate causes of his death.
Following the hearing at Sheffield Town Hall, Mrs Rawnsley said: “When he was moved to Sheffield to a ‘specialist service’ run by Lifeways, this was against his and our wishes.
“Thomas’s physical and mental health declined rapidly and his family screamed out for help.
“We trusted in the coronial process however the inquest wasn’t able to examine any of the wider failings in care, the abuse he suffered, the lack of trauma support or why Thomas couldn’t live in his local community.
“It simply looked at the last five days of his life.”
She said: “I have found the process extremely distressing especially as it continued during a pandemic and during a national lockdown.
“The jury were instructed that the only finding they could reach was that Thomas died from natural causes. We are left wondering how it can be natural for a fit and healthy 20-year-old to die from a chest infection.”
“Thomas was a beautiful, loving, compassionate and most of all mischievous little boy.
“He enjoyed spending time with his family and was loved like only a youngest brother to three big sisters can be.
“Thomas was a very much loved son, brother and uncle.”
She told the jury her son’s condition deteriorated during his time in Sheffield, telling the inquest: “I felt I was banging my head against a brick wall and things were getting more and more desperate.”
Sebastian Del Monte, of Hodge Jones & Allen Solicitors, acting on behalf of Thomas’s family, said: “Thomas’s death is yet another example of how individuals with learning disabilities are failed in a health and care system ill-equipped to assist adults with complex care needs.”
He said: “The jury’s conclusion is not a vindication of the overall care afforded to Thomas. We have heard evidence to suggest that Thomas had been failed by authorities throughout his short life and although an inquest’s role is not the same as that of a public inquiry, it is a tragedy that lessons will not be learned from Thomas’s death almost as much as it is a tragedy for Thomas’s family.”
Mr Del Monte said the coroner’s ruling that Article 2 of the European Convention on Human Rights was not engaged was crucial. Article 2 engagement relates to the state’s responsibility to keep anyone under its care or control safe, and leads to a wider investigation by coroners at inquests.
Mr Del Monte said: “The fact that we do not hold privately run care homes to the same standard as prisons or hospitals – where Article 2 is always engaged – is deeply concerning to me.”
Failed Health Care System
Deborah Coles, Director of INQUEST a charity that supports bereaved families including Thomas’ family, said: “Thomas’ death is being dismissed as ‘natural causes’ is shocking when the family had raised a series of safeguarding concerns and that staff responsible for his care lacked training. Not to mention the many unanswered questions about the poor history of care and failings that were not allowed to be a part of the inquest.
Paula fought for her son in life and the system failed him. It has failed this family again by not delivering the scrutiny needed. Currently, inquest and investigation systems are failing to consistently and effectively shine a light on issues leading to the widespread premature and unexpected deaths of people with learning disabilities.
We need clearer guidance for coroners on when Article 2 can be engaged in these cases, to enable a more in-depth inquest, alongside decent investigations with the involvement of bereaved families, in order to build national oversight and encourage much needed policy and cultural change.”