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The coroner raised the following matters of concern: Jeesal Cawston Park (JCP) Jeesal Akman Care Corporation was the care provider for JCP and closed in 2021. However, Jeesal Holdings Ltd, Jeesal Residential Care Services Ltd (JRCSL) and possibly other linked companies with the same directors, continue to provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability. The concerns raised at the inquest could apply to residential care offered by these companies and unless such concerns are addressed there is a risk that future deaths may occur. It is not known if the directors of these companies are directors of other companies providing care for persons with learning and other disabilities. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL. Basic dietary advice and guidance provided was not followed by staff. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (for example, Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns. Norfolk and Norwich University Hospital (NNUH) Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020: The Discharge Form provided under “Other” - “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. CPAP and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk/benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. Promethazine would appear to be such a medication. Arterial and venous blood gas samples were taken from Ben King on his attendances on 9 and 10 July 2020, which the Respiratory Consultant said in evidence were incomparable (although this was not the evidence of the Expert Respiratory Consultant). No blood gas samples were taken on the 12 July 2020. A copy of this report was sent to: The Chief Coroner Clinical Commissioning Group Norfolk Safeguarding Adults Review Group Care Quality Commission Department of Health Healthcare Safety Investigation Branch (HSIB) Healthwatch - Norfolk

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Key recommendations Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management. Routine use of a videolaryngoscope is recommended whenever feasible. At each attempt at laryngoscopy, the airway operator is encouraged to verbalise the view obtained. The airway operator and assistant should each verbalise whether ‘sustained exhaled carbon dioxide’ and adequate oxygen saturation are present. Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded. The default response to the failure to satisfy the criteria for sustained exhaled carbon dioxide should be to remove the tube and attempt ventilation using a facemask or supraglottic airway. If immediate tube removal is not undertaken, actively exclude oesophageal intubation: repeat laryngoscopy, flexible bronchoscopy, ultrasound and use of an oesophageal detector device are valid techniques. Clinical examination should not be used to exclude oesophageal intubation. Tube removal should be undertaken if any of the following are true: Oesophageal placement cannot be excluded Sustained exhaled carbon dioxide cannot be restored Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide. Actions should be taken to standardise and improve the distinctiveness of variables on monitor displays. Interprofessional education programmes addressing the technical and team aspects of task performance should be undertaken to implement these guidelines.