Jonathan Metzer was instructed by Carl Rix of Fosters Solicitors to represent the mother of Ben King at a two-week inquest into Ben’s death. Ben was a 32-year old man with Down’s syndrome, associated obstructive sleep apnoea, and a severe learning disability. He had spent over two years at Cawston Park Hospital and was held under the Mental Health Act.
Ben’s weight increased dramatically in the 14 months leading up to his death however, the Multi-Disciplinary Team did not identify weight loss as a goal for him. Dietary advice was not properly followed and the number of physical activities he was offered decreased. In July 2020 Ben was taken to A&E three times for breathlessness and low oxygen saturations but not admitted. In the opinion of the expert witness, this weight gain led Ben to develop the life-threatening condition of obesity hypoventilation syndrome, which was not appropriately diagnosed.
On the morning of 28 July 2020, staff recorded that Ben had oxygen saturations of 35%, far lower than the ordinary range of 95-100%. He was also displaying signs of abnormal breathing, drowsiness and, at times, blueness to his lips and fingers. However the consultant and speciality doctor both advised against using oxygen or calling 999. In the evening, Ben was given the sedative promethazine in accordance with instructions to calm him, which the expert witness believed led to significant respiratory deterioration. Throughout the night he was not regularly observed by staff, he collapsed after trying to stand and subsequently stopped breathing and a police investigation into potential physical assault is ongoing.
The Jury concluded that Ben “died due to inadequate weight management and failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine” and that there was a “failure to identify the seriousness of a life-threatening situation”. The Coroner made a Regulation 28 Report to prevent future deaths which identified 10 items of concern relating to the company which ran Cawston Park and 6 items of concern relating to Norfolk and Norwich University Hospital NHS Foundation Trust.