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Rachel’s Voice representation at Mencap Healthcare Inequalities Summit 2023
Our Director Caron Heyes attended the first Health Summit hosted in the Great Hall of St Bartholomew’s Hospital in April 2023. The event was chaired by the Duchess of Edinburgh, Patron of Mencap, with attendees including NHS leaders, Mencap Executives and campaigners from Mencap’s Treat Me Well campaign.
The summit heard about actions to improve life expectancy, avoidable deaths and other healthcare inequalities experienced by people with a learning disability; including goals to see everyone with a learning disability on the Learning Disability Register with their Doctor and the Oliver McGowan Mandatory Training on Learning Disability and Autism which is being rolled out to NHS staff swiftly.
Caron was invited to contribute to the discussions from a legal perspective and from her experience in representing families at inquests.
One of the points she was able to raise was an ongoing practice we see of learning disability being included on death certificates as a contributing factor to their death. It was a great indignity for one of our clients to sit through painful evidence of how her sister died as a result of injuries related to her physical frailty and be told that those injuries were contributed to by her learning disability. Her learning disability meant that she was unable to verbalise her experience and needs, and we were successful in our arguments in the coroner’s court to have learning disability removed from the certificate altogether.
We strongly feel that learning disability should never be listed as such because usually, it is the failure to accommodate additional needs presented in someone with a learning disability that contributed to the death than the learning disability itself, as Caron noted in her speech at the Summit.
One of the outcomes of the Health Summit was an invite from NHS England to contribute to discussions on issuing new guidance around death certification to ensure that intellectual ability is never considered as a contributing factor for someone’s death.
See more about the Health Inequalities Summit here
Attendance at AvMA Representing Families at Inquest Conference
Hosted at Gatehouse Chambers, Emily Sherratt attended the Conference to learn more about practices and procedures for representing a family at an inquest. Emily heard about AvMA’s work and experiences when representing families at inquest during and after the Pandemic, trends in their casework and recent changes to legislation and caselaw.
Of particular note to Rachel’s Voice cases, Emily learned more about Article 2 inquests (where someone dies under the care of the state) and tips for Preventing Future Death hearings.
New inquest listed for December 2023
The second inquest as part of the Rachel’s Voice project will be heard on 12th and 13th December at Hertfordshire Coroner’s Court, touching upon the death of Wendy Liebert.
Wendy died aged 38 years old after sustaining injuries whilst a resident at St Elizabeth’s Centre; a privately run care home in Hertfordshire.
Fieldfisher will be representing the family pro bono as part of this project.
Lyn Parker Inquest
The jury hearing the evidence into the death of 64-year-old Lyn Parker, who died after she was dropped 1.5m from a mechanical hoist by care workers at the home she had lived in for 30 years, concluded in a narrative verdict that the fall contributed to Lyn's death.
Press reports Lyn Parker inquest following narrative verdict
The jury hearing the evidence into the death of 64-year-old Lyn Parker, who died after she was dropped 1.5m from a mechanical hoist by care workers at the home she had lived in for 30 years, concluded in a narrative verdict that the fall contributed to Lyn's death.
Lyn needed around the clock care after sustaining a brain injury at birth. She had very limited communication.
The care home dialled 999 but because of the information given to the ambulance service, Lyn was categorised as non-urgent. She was eventually taken unaccompanied by ambulance to Kingston Hospital on 15th January, having been left lying on the floor for three hours with fractured ribs and arms. She was discharged back to the home later that day having been diagnosed only with a fracture to her right arm.
During the morning of 16th January, her health seriously deteriorated and she went back to the hospital where she was found to have much worse injuries over her whole body, including a left arm fracture, broken ribs and aspiration pneumonia. Lyn died on 25th January.
In written evidence presented at the inquest, Lyn's treating A&E doctor admitted he 'should have' arranged a trauma CT scan and, had he done so, Lyn would have been admitted to hospital that evening.
A Safeguarding review conducted by the London Borough of Richmond found neglect on the part of the residential care home, run by Certitude.
Following the inquest, Kim Parker told the press that her feelings of betrayal and anger at the people meant to be caring for her sister have not abated in the two years since she died.
'My job right now is to speak up for everyone with vulnerable relatives in care to demand that they are treated properly and fairly," Kim said. "These terrible failings must not be forgotten or glossed over, and promises kept that things will improve. They have to, or Lyn will simply become another statistic, and that would be unbearable.'
Caron Heyes, representing the Parker family, said that the evidence at inquest had been difficult to hear.
'Lyn was the tragic victim of catastrophic failures of care that were simply not acceptable and caused her avoidable death. No one wants to be in a care home, but you have to know it is safe. To hear that the most vulnerable can be treated so carelessly should appal us all.
'We cannot go on and on hearing about failures to protect people with learning disabilities from avoidable errors in care. It is up to the institutions involved to listen, learn and to keep their promises to ensure people in their care are safe.'
Read the full report by ITV
Caron Heyes leads a pro-bono project called Rachel's Voice between Fieldfisher and Mencap to raise awareness of inequality in the healthcare system of people with learning disabilities, focusing on reducing the numbers of deaths caused by avoidable mistakes in medical treatment. Importantly, Caron was successful in having the term 'learning difficulties' as a cause of death removed from Lyn's death certificate. This is important since a learning difficulty is never a cause of death.
Caron previously represented the family of Rachel Johnston who also had learning difficulties. Rachel died from hypoxia after having all her teeth removed, while the care home where she lived failed to notice her deteriorating condition. The coroner concluded neglect contributed to Rachel's death, with the finding that she was discharged with inadequate information, and a gross failing of the care home to provide basic medical care, causing her to suffer a cardiac arrest and later die.
This case echoes previous cases where focus on the learning disability rather than on relevant clinical factors, or a lack of accommodation of need, contributed to care failures, or where appropriate equipment and treatment were not provided, or patient concerns about their health were not investigated.
Subsequently, Caron and Mencap launched the Rachel's Voice campaign to highlight serious inadequacies in the care given to people with learning difficulties.