Mother's fury at hospital over death of son with Down's syndrome

Ben King, died at Cawston Park Hospital on July 29 2020

Ben King, died at Cawston Park Hospital on July 29 2020. An inquest into his death made a number of criticisms of the care he received. - Credit: Supplied courtesy of Ben King's family

The devoted mother of a man with Down's syndrome who died after inadequate care a Norfolk hospital today said: "I expected them to look after him."

Gina Egmore spoke at the end of the inquest into the death of Ben King, 32, who was a resident at Cawston Park, near Aylsham.

The Norwich inquest into the death of Mr King found major failings in the care he received.

Mr King, who also had a severe learning disability, died at the Norfolk and Norwich University Hospital (NNUH) on July 29 2020.

Ms Egmore said: "I looked after Ben for the first 30 years of his life, and I expected that he would be properly cared for when he was transferred to Cawston Park.


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"However, the evidence heard at the inquest suggests this clearly wasn’t the case.

"Whilst nothing can ever make up for the devastating loss of Ben, given the jury’s conclusion I can take some comfort from knowing that I managed to obtain justice for my son.”

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Ms Egmore said her son was a friendly and loveable person who enjoyed swimming and spending time with his dogs.

At the time of his death, Mr King had been an inpatient at the Jeesal Group-owned hospital for two years.

His death was the third of three to take place in questionable circumstances at the hospital, which specialised in caring for people with learning disabilities, between 2018 and its closure earlier this year.

Cawston Manor

Cawston Park hospital, near Aylsham pictured from above. The hospital closed in May 2021. - Credit: Mike Page

During a two-week inquest into Mr King's death, Jacqueline Lake, senior coroner for Norfolk, and a jury heard Mr King was transferred to Cawston Park on July 8, 2018.

During his time there, he was detained under the Mental Health Act. 

The court heard Mr King had obstructive sleep apnoea, a non-life-threatening condition that is common in people with Down's syndrome. Treatment involves using a CPAP machine for long periods, something Mr King struggled with.

If someone with sleep apnoea is also overweight, they can develop a breathing disorder called obesity hypoventilation syndrome. Without weight loss, this can increase blood pressure, breathlessness, and lead to death.

Norfolk's new coroner Jacqueline Lake.PHOTO BY SIMON FINLAY

Jacqueline Lake, senior coroner for Norfolk - Credit: Simon Finlay

The inquest heard Mr King received one-to-one exercise support from Mencap from April 2017 to June 2019 but when this stopped due to a lack of funding, Cawston Park staff reported Mr King did not engage as much in planned activities.  

Mr King gained more than two stones in the months leading up to his death but the multi-disciplinary team at Cawston Park did not identify weight loss as a goal.

Evidence was also heard that the number of physical activities Mr King was offered dropped considerably at the end of 2019.

While at Cawston Park, Mr King was prescribed the sedative promethazine. The inquest heard it was initially prescribed to help him comply with his CPAP machine but the drug was then used to control behaviour. 

Sedatives can be dangerous for people with respiratory issues, however care staff told the inquest they were not aware of these risks.

Significant concerns were raised by CQC inspectors at Jeesal Cawston Park Hospital. Pictures: David

Significant concerns were raised by CQC inspectors at Jeesal Cawston Park Hospital. Pictures: David Bale - Credit: Archant

The court heard how, a few weeks before his death, Mr King was taken to A&E three times as a result of having low oxygen saturation and breathlessness. The inquest heard expert evidence to suggest that a diagnosis of obesity hyperventilation syndrome was possibly missed on these occasions.

In the early hours of July 28, 2020, staff at Cawston Park recorded Mr King's oxygen saturation as being 35pc. A percentage under 70pc is considered life-threatening.

Low levels were continually recorded over the next 24 hours, and at times Mr King had blue lips and fingernails. A consultant was called and advised against using oxygen or dialling 999.

Mr King's mother visited her son on July 28 and requested an ambulance be called.

That evening Mr King was given promethazine. At 1.15am on July 29, his oxygen saturations were recorded for the last time, at 35pc. Just before 3am he went to sleep on his stomach, despite the treatment plan discouraging this. No observations were recorded again until 5.05am. 

At 7.07am, a nurse went into Mr King’s room, but could not rouse him and called 999. CPR was commenced and Mr King was taken to the NNUH where he died that evening. 

An expert told the inquest that it was unlikely Mr King would have developed respiratory deterioration in July 2020 if he had not gained weight.

Cawston Park. Picture: EDP Library/submitted

Cawston Park Hospital closed in May 2021, having been in special measures due to a number r of failings since 2019.

Closing the inquest Ms Lake concluded Mr King “died due to inadequate weight management and failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine.”

The inquest jury also found that there was a “failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine”, as well as a “failure to identify the seriousness of a life-threatening situation."

Ms Lake is yet to make a decision as to whether a report to prevent future deaths.

The Jeesal Group has been contacted for comment.

A chequered past

Ben King is one of three patients to have died under contentious circumstances at Cawston Park Hospital since 2018.

Joanna Bailey, a 36-year-old woman who had learning disabilities, died of sudden unexpected death in epilepsy at the hospital in April 2018. An inquest heard she was not checked for two hours that night, despite 30-minute checks being in her care plan.

Nicholas Briant, 33, died at Cawston Park on October 31 2018. He had learning disabilities and a known history of consuming objects. He died after swallowing a piece of plastic cup. An inquest found his death was by misadventure.

Cawston Park Hospital closed in May 2021, after CQC inspectors reported the Dereham based Jeesal Group, which ran the hospital was "unable to demonstrate improvements".

The hospital had been in special measures since November 2019.

At the time of its closure, it had 46 patients.

What is Jeesal Group?

The Jeesal Group is based in Dereham and was set up more than 30 years ago by Jeeva and Sally Subramaniam.  

It specialises in providing “a caring and nurturing environment to people with developmental disabilities live fulfilling lives” .

The group bought Cawston Park in 2010 with "the aim of being able to provide clinical care and treatment and supporting people as quickly as possible back into the community". 

When the hospital closed Tugay Akman, Jeesal's chief executive, said he felt "disappointed and frustrated".

The group comprises of Jeesal Residential Care Services Ltd, Jeesal Akman Services and the Jeesal Akman Care Corporation Ltd. 

Jeesal Care has homes for people with learning disabilities in Cromer, Hellesdon, Buxton and Norwich.




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