Coroner to consider making prevention of future deaths report following the death of London man with Down syndrome who lived at Surrey care home.

A coroner has said she has questions about how Ballater House Care Home in Surrey treats diabetic patients with low blood sugar, and about the home’s emergency alarm systems, following the death of a male patient.

Assistant coroner for Surrey Caroline Topping confirmed she will decide whether to issue a Prevention of Future Deaths report after concluding that the patient died aged 41 after choking because of undiagnosed oesophageal cancer in September 2023. She said further causes of death were Daniel’s learning disabilities and Down syndrome.

The full inquest was held at Woking Coroner’s Court from 22 June to 24 July and heard six days of evidence. 

“The evidence heard at [the] inquest has raised important issues around the role that families and carers play in supporting individuals who cannot communicate their care needs for themselves, particularly those with learning disabilities,” said Leigh Day human rights solicitor, Sarah Westoby. 

Unanswered questions

The patient had moved to Ballater House in November 2020. Although Topping concluded that the patient’s care did not contribute to his death, she said his case had left unanswered questions about the systems in place at Ballater House Care Home in Chipstead.

She found that the patient, who was also a Type 1 diabetic, could not easily communicate his needs because of his learning disabilities and Down syndrome. 

In her conclusion, the coroner said the patient experienced a hypoglycaemic event on the evening of 23 September 2023, from which he recovered. However, no blood sugar reading was taken before he was left unattended. Shortly after being left alone, he was found vomiting and refusing to sit up.

The coroner has asked Ballater House for a response on issues including that, where someone is suffering a hypoglycaemic episode, they will not be left alone before a blood sugar reading has been taken. She also questioned whether the home’s emergency alarm systems were effective.

“We hope this inquest process will enable Ballater House and the wider care community to reflect on its practices and help ensure that no one else is put through what [the patient] had to endure,” added Westoby.