Charity says '˜lessons have been learnt' after Gosport man's tragic death
LESSONS have been learned by a charity after an epileptic autistic man died in Gosport while under its care.
Michael Bennett was found collapsed and unresponsive by staff at 102b Brockhurst Road where he was in the care of the charity Autism Hampshire on Sunday, March 29, 2015.
The 22-year-old was given CPR at the scene and taken to Queen Alexandra Hospital in Cosham, where he was pronounced dead.
But a two-day inquest into his death at Portsmouth Coroner’s Court revealed there had been shortcomings in the care given to Michael.
The court heard Mr Bennett needed 24-hour support and that he suffered from regular epileptic seizures that had been intensifying in frequency in the months before his death.
But coroner David Horsley heard that staff at the home would leave Michael alone in his room, unattended, for hours at a time over the weekends, allowing him to ‘sleep in’ late into the morning.
Mr Bennett’s mum Tracey, of Totton, near Southampton, told the court she had been worried about standards at the home.
She explained her son would come home every other weekend and had noticed ‘worrying changes’ in his morning routine.
But she said the family didn’t want staff to think they were ‘fault-finding’ so she did not question the matter.
She said: ‘I recall saying to staff many times “I worry when he is in his room”.
‘As parents, we were in a difficult position.
‘You want to have a good relationship with those who cared for Michael but also hold an expectation of a certain level of care.
‘Standards at the house were not the same as ours.’
She added she had ‘no idea’ her son was being allowed to lie in at weekends, which resulted in him being ‘unsupervised’ in his room for ‘long periods of time’.
‘It was abhorrent to us,’ Mrs Bennett said of the practice.
‘When we learned of this from Autism Hampshire’s draft report our hearts sank and alarm bells sounded.’
She said staff should have been checking him every 15 to 20 minutes – as was required when he had a seizure.
‘Why were 15 to 20-minute checks not done in case he had a seizure as a preventative measure in addition to a reactive measure?’ she asked.
Pathologist Dr Adnan Al-Badri told the court there was ‘no doubt’ Mr Bennett had died from a rare condition known as sudden unexpected death in epilepsy – or Sudep.
He explained even if carers had been with Mr Bennett when Sudep hit ‘there would have been nothing they could have done’ to save him.
Deborah Sales, Autism Hampshire’s chief executive said ‘immediate action’ was taken to improve service across their 10 homes.
This included better training, ‘more robust procedures’ and a review of all risk management protocols.
She added homes now had better communication with families of service users.
Coroner David Horsley said the home was not at fault for Mr Bennett’s death and that he died of natural causes.
Paying tribute to her son, Mrs Bennett said: ‘Everybody loved Michael. He was a happy boy and had an infectious giggle and super sense of humour.’