Major safeguarding failures found at Somerset care campus after woman chokes to death
The 60 year-old woman, referred to in the report via the pseudonym 'Hazel', had been diagnosed with autism, a learning disability, and Bell's palsy.
She died in July 2019 after choking on a sandwich at Somerset Court in Brent Knoll and had lived on the campus, which housed multiple residential units for people with autism, since the age of 15.
An independent Safeguarding Adults Review, published by the Somerset Safeguarding Adults Board, concluded that Hazel's death was preventable.
It criticised serious shortcomings in her care, including poor risk management, a lack of coordinated support, family engagement and failure to follow her health care plans.
Crucially, the report highlights that these failings occurred just a year after a damning safeguarding review into abuse at Mendip House, which was another residential unit on the same National Autistic Society site.
Staff at Mendip House were found to have mocked and humiliated residents.
Despite national scrutiny following the Mendip House scandal in 2018, the review found that the lessons were not learned or applied across the rest of the campus.
Hazel's home was affected by high staff turnover, agency workers unfamiliar with her needs, and inadequate oversight particularly troubling for someone who relied on routine and consistency to manage her anxiety.
The report also criticised agencies for failing to work together, failing to escalate repeated safeguarding concerns, and for not involving Hazel's family or providing advocacy when decisions about her care were being made.
Speech and language therapy recommendations about Hazel's choking risk were known but not properly communicated to all staff.
Since Hazel's death, a new Multi-Agency Risk Management (MARM) framework has been introduced locally, and all campus-style services like the one Hazel lived in are being phased out nationally under the Transforming Care programme.
The review calls for urgent action to ensure that out-of-area placements for people with disabilities are subject to better oversight and regular review.
It also recommends mandatory dysphagia and autism training for all care staff, especially those employed through agencies.
Professor Michael Preston-Shoot, Independent Chair of the SSAB said: "The Somerset Safeguarding Adults Board exists to protect people at risk of abuse and neglect and to make sure lessons are learned so that necessary improvements can be made.
"I want to take this opportunity to offer Hazel's family my sincere condolences for their loss."
He added: "Hazel's tragic story has highlighted that further work is required to sharing information across our organisations to safeguard those with support & care needs and learning disabilities in Somerset.
"I am pleased to see that the organisations involved were open to these improvements and lessons have been learned with many changes having already been implemented. I will now work with SSAB partners to ensure that this learning becomes normal practice."
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