Page 23 - Community Living Magazine 35-2

premature deaths

Within a week, a safeguarding review
had been opened and closed without our Sadly, families are often
knowledge. We have never had an perceived as an irritant before
explanation why a safeguarding review was
not undertaken by the York Safeguarding and after a premature death,
Adults Board in line with the Care Act 2014. and discouraged from
After Danny’s death, we sought legal
advice and it took two years to get an demanding answers
inquest opened. If Danny’s case had fallen
under the deprivation of liberty
safeguards – it was confirmed he would Dying to Matter could provide a supportive
have qualified – this would have network between families and evidence of
happened automatically. similar issues that arise from care-related
We were refused legal aid although all deaths to bolster campaigning.
public bodies have their costs met by For us, the lack of change in local services
public funds. The Care Quality has been hugely disappointing. The
Commission (CQC) soon inspected some coronial verdict meant that any impetus
Mencap houses including Danny’s and to improve among agencies was lost.
found “requires improvement in all areas” There is no evidence that people in York
for Mencap’s entire domiciliary care with Danny’s profile now have robust
service in the area. Danny Tozer “was not given a chance to survive epilepsy plans monitored and reviewed.
Having taken over the Health and Safety when out of sight or sound” Mencap has never initiated any contact
Executive role, the CQC investigated over with us since Danny’s death or inquest and
nine months whether Mencap should be To our surprise – and to the surprise of the current chief executive has said that
charged with manslaughter, without other parties involved and legal and social she cannot comment on anything that
contacting us or City of York Council. care commentators – neither neglect nor happened before she was in post.
It concluded that, as it was not known any other failings were mentioned. We are all aware of the discriminatory
when Danny had a seizure, he might not attitudes to the lives of disabled people
have survived anyway. This seemed Chance lost for a positive legacy that pervade our society and even the
illogical to us and, crucially in our opinion, So why is it important that the deaths of structures designed to support them to
Danny was not given a chance to survive Danny and others with learning reach their potential.
when out of sight or sound. disabilities in similar circumstances are If independent advocacy is not available,
After nine months, the council known about? then frequently only the diligence of
commissioned a management review, We know that people with learning families can ensure the safety and
which found failings by the council and disabilities die, on average, 20 years wellbeing of their relative, and often filling
Mencap and that Danny “should not have younger than their peers and these figures in gaps in provision. This has become
been left as long as he was” – although have not improved in recent years (LeDeR, sharply apparent in recent times with cuts
the reviewer never visited the house. 2020). Only half of those with autism, to services and Covid restrictions.
Following this, the council apologised learning disabilities and epilepsy reach But we must not forget the deaths that
and said it could have done things better, their 40th birthday (Autistica, 2016). preceded or have happened alongside
agreed that the placement was unsuitable Bereaved families often want to see the pandemic. Aside from financial
and wrote a “DT action plan” – reducing positive changes in services that could resources, inclusive attitudes and caring,
his identity to initials. prevent further deaths – a legacy from a constructive approaches are paramount
Mencap did not undertake an internal senseless event. But they are largely while we await and campaign for societal
inquiry until two years after Danny’s powerless to achieve this as authorities and legal change. n
death; the family was unaware of this and are likely to close ranks to preserve their ● Danny Tozer: a Preventable Death? by
it was not presented at the inquest six reputations and the status quo, so Katharine Quarmby can be read at http://
months later. It suggested that the positive change is not achieved. dyingtomatter.org.uk/deaths-in-care/
family’s expectations of the placement Families are frequently isolated and danny-tozer-a-preventable-death/
were unrealistic and staff did not engage unsupported at this time, confused about
with us for fear of confrontation. what should happen after their relative’s In the next issue, Alicia Wood and
An article 2 (right to life) inquest was death, which authorities can prefer to Katharine Quarmby, who launched Dying
held in April 2018. The City of York Council present as a one-off – a blip in the system to Matter, will discuss the ongoing
and Mencap staff who gave evidence rather than the ultimate consequence of a implications of Danny Tozer’s death, and
seemed to have little recollection of much closed culture. how preventable deaths can become a
of what had happened and portrayed Sadly, families are often perceived as an thing of the past
their practice as entirely acceptable. irritant before and after a premature
The coroner concluded in one sentence death, and discouraged from demanding References
that Danny had died from natural causes answers to why it has occurred. Once we Autistica (2016) Personal Tragedies, Public
and said that it would have been too were offered a patronising hug instead of Crisis. The Urgent Need for a National
Response to Early Death in Autism. https://
answers to our questions.
difficult to keep him safe.
Rosemary Tozer between the council, Mencap and the advice from people associated with the tinyurl.com/2p8b5erk
By chance, we did find support and
He did comment that communication
Learning Disabilities Mortality Review (LeDer)
Programme (2020) Annual Report 2020.
https://tinyurl.com/yvvspcur
family was not satisfactory.
Justice for LB campaign. Initiatives such as
www.cl-initiatives.co.uk Community Living Vol 35 No 2 | Winter 2022 23