Inquest hears evidence of ‘unhealthy culture’ at residential home

Fosters Solicitors has recently supported the family of Holly Goodchild at the inquest into her death, which concluded at Norfolk Coroner’s Court on the 9th December.

The 29-year-old, who had a diagnosis of learning difficulties, a personality disorder, autism, and epilepsy, had been a resident of Cygnet House in Great Yarmouth since 2018. Described as “friendly, caring and very affectionate” by her family, tragically on the 29th March 2023, Holly passed away at the home after collapsing with a seizure.

The six-day inquest heard about Holly’s life and the events leading up to her death, including evidence from four staff members of the home, run by Crystal Care Solutions, examining their response to Holly’s collapse and the management of her care plans.

Senior Coroner, Jacqueline Lake, addressed the inquest highlighting the many concerns raised by the evidence and that an unhealthy culture had developed at Crystal Care at the time of Holly’s death. Holly’s risk and management care plans were not always being followed and her diet was not being controlled. A postmortem report was also referenced, concluding that Holly had died due to positional asphyxia due to, or as a result of, epilepsy and morbid obesity – with the court hearing that Holly “would probably have survived”, if she had been moved within the first five to six minutes of her seizure.

Paying tribute to Holly, Holly’s Mother (Janice Humble) and Sister (Connie Goodchild) provided a joint statement:

“Our beautiful Holly sadly died at Cygnet House, Crystal Care, Belton, Great Yarmouth, on 29th March 2023, under the care of untrained support workers, who thought that Holly was ‘playing up’, when she had actually suffered a seizure. Holly was left by Steeven Souciant and Daniel Soanes on the floor, not in the recovery position. Her airways were blocked, and she was unable to breathe, which they did not realise, leading to Holly’s death.

“This has caused irreversible suffering to our family. We will never forgive, nor forget, the horrific night of Holly’s death. We would never wish another family to go through such heartache and pain at the loss of their loved one. will be forever remembered for her infectious smile and her heart full of love. Her memory will forever live on through all those that knew Holly, especially her family. Holly will always be loved and missed by her “mummy darling”, father, brother, sisters, nieces, and nephews.”

Jenny Fraser of Fosters Solicitors, representing the family, added: “The death of Holly is a true tragedy and was preventable. This ought to be a warning to all those caring for the most vulnerable in our society. They have the responsibility to protect and provide safety to those who cannot do this themselves. I hope that Crystal Care have learnt lessons and will now take the time to review their systems, and services, to ensure that all staff are fully trained and more importantly, competent to carry out their role. No family should ever go through this.”

A full summary of the inquest:

Inquest into the death of Holly Jeanne Goodchild

Before HM Senior Coroner Jacqueline Lake
Norfolk Coroner’s Court, Norwich
2nd December – 9th December 2024

The family was represented by Jenny Fraser and Lucas Allum from Fosters Solicitors and Carl Rix from Old Square Chambers.

Holly Goodchild was a 29-year-old lady born 12 February 1994 in Walton on Thames, Surrey. She passed away on 29 March 2023 at Cygnet House, Great Yarmouth, Norfolk.

Holly was diagnosed with learning difficulties, a personality disorder, autism and epilepsy. Described as friendly and caring by her family and very affectionate, Holly loved nothing more than spending time with her friends and thoroughly enjoyed swimming and horse riding.

An inquest into Holly’s death was held at Norfolk Coroner’s Court, wherein witnesses were called from Crystal Care, Norfolk County Council and The East England Ambulance Service.

Background

Holly had relied upon the care system since she was a child, due to the challenging behaviours that she presented with on account of her learning difficulties and personality disorder. From 2012, she had been held under both Section 2 and 3 of the Mental Health Act 1983. Holly was transferred from Cawston Park Hospital to Cygnet House (supported living accommodation operated by Crystal Care) on 28 March 2018. In January 2018, Holly weighed 86kg and had a BMI of 29.7. By November 2018, she weighed 114kg and at the time of her death on 29 March 2023, she weighed 144kg and had a BMI of 46.9.

There were a number of issues prevalent within her time at Crystal Care, with the management of her weight and finances being key to these. Holly was deemed to have capacity for her diet and nutrition but not for her finances. Notwithstanding this, evidence was heard that Holly would spend all of her money on junk food and takeaways, even selling her possessions to get more money to spend on takeaways. It was not until January 2023, after input from Holly’s social worker (Emma Lane) that a plan was put in place with Crystal Care to restrict Holly’s finances to prevent her being able to purchase takeaways and junk food. Michelle Smith (Operations manager at Crystal Care) was not able to provide an answer as to why it took 5 years for a restrictive plan such as this to be put in place for Holly. Moreover, despite having full Care, Risk and Management Plans in place, to ensure Holly was receiving adequate care to safeguard her, these were not always followed by staff nor was her diet always controlled.

Emma Lane gave evidence that Holly needed strong and confident staff to manage her behaviour and to enforce her care plans. Michelle Smith gave evidence that at the time of Holly’s death, they did not have sufficient strength of staff due to their difficulties in recruitment and over-reliance on agency staff. Angela Pilgrim, a support worker who frequently worked with Holly, explained that she was a “pushover” with Holly and that she would not make Holly do things that she did not want to do, even stating she would give Holly cans of fizzy drinks.

Activities are noted to have been a consistent struggle with Holly. Staff reported that they offered Holly activities on a day-to-day basis, but that she would not want to do these. Their evidence was that an option for an activity would be offered, Holly would say no, and the staff would then not take this any further. It is noted that these offers were not documented by Crystal Care staff. As an example of Holly’s day, on 28 March 2023, the day before her death, Holly was noted to be on her phone, smoking, sleeping, and eating. She was also on social leave between 13:30 and 16:00. This was explained to be going shopping and out for food.

In relation to the events of Holly’s death on 29 March 2023, conflicting evidence was heard from the 4 staff members involved: Angela Pilgrim (Support Worker), Ana Sampaio (Support Worker), Daniel Soanes (Support worker) and Steeven Souciant (Senior Support Worker). It was accepted that Holly had not taken her evening epilepsy medication and that in this event, Holly’s care plan stated that 111 or the pharmacist should be called for advice; this did not happen.

On 29 March 2023, just after 20:00, Angela and Ana were at Holly’s house, going through the shift handover in the kitchen. Holly was stood in the porch having a cigarette and cup of tea. They were not observing Holly at this time. Shortly after 20:00, evidence was heard that Holly screamed or cried out and that Angela and Ana immediately went to Holly and found her on the ground in a prone position, with her legs out of the door. Angela’s evidence is that Holly was convulsing, whereas Ana suggests that Holly was laying unresponsive on the floor. (Ana’s evidence was preferred by the Coroner).

Evidence was heard that Ana then telephoned Steeven and told him that Holly was on the floor and that she needed help. Steeven arrived and was informed that Holly had put herself on the floor. He stated that Angela had told him that Holly had been challenging all day before this incident. Steeven thought Holly was “playing up” and that he thought this was a common behaviour for her, though he accepted he had never seen Holly lay on the floor like this before. Contrary to Holly’s epilepsy care plan, which states that 999 should be called immediately in the event of seizure, it was Ana and Angela’s understanding that they should call at senior staff member, who would then take the decision of whether to call 999. This is why Steeven was called in the first instance, not 999.

Ana and Angela both gave evidence that they told Steeven to call 999; he gave evidence to suggest that he was not told to do this. It was not until 20:34 that Steeven decided to call 999. On this call he informed them that he could not see Holly’s face and that it was covered by a tea towel. He stated she was conscious, breathing and that he thought she was “playing up”. He also stated that he thought this was part of her learning difficulties and that she liked attention. It was Ana’s evidence that Holly had been unresponsive in this time.

Around this time, Daniel and Ana had been swapped, with Daniel coming to assist at Cygnet House and Ana going to Swanrise, a different home on the grounds. The reason for this was given as Ana, being Portuguese, was not able to understand the instructions that Steeven was giving her. Daniel confirmed that Holly was responsive, stating she was making grunting noises. Daniel stated that Steeven had told him that the 999 operator had said not to move Holly. This was not correct and was not evident in the recording of the phone call.

Ana explained that she did not think Holly was playing up and did not think that someone could act for this length of time. At approximately 21:26, Steeven examined Holly again having been around her since the first call. He thought that Holly had deteriorated and so called 999 again. On this call it was not established whether Holly was breathing, Steeven suggested that she had been breathing, but that he now could not tell. Whilst on the phone to 999, the paramedics arrived at 21:34.

Paramedic Amie Moore gave written evidence that on her arrival, Holly was kneeling on the floor in the porch entrance, leaning forward, with her chest towards the floor, chin to chest and buttocks towards the ceiling. This is consistent with the support workers evidence as to how Holly had been positioned since shortly after 20:00. Holly was moved within 1-2 minutes and was found not to be breathing and with no cardiac output. CPR commenced but was unsuccessful. Time of death was recorded as 22:16.

Histopathologist, Professor Ball provided evidence for Holly’s cause of death. His conclusion was that, on the balance of probabilities, Holly suffered a seizure. He then opined that the position she was in was compromising her breathing, due to the weight of her body on her chest and the position of her face, with her chin being tucked to her chest. It was his opinion that had Holly been moved in “a few minutes” then she would, on the balance of probabilities, have avoided her death. His evidence was that if there was not a complete cessation of breathing, then the time in which you have to move someone is “prolonged”. The Coroner was satisfied that Holly was breathing until at least 20:34 at the time of the first phone call.

All four witnesses confirmed that they would have moved Holly if they thought her breathing was obstructed. They also confirmed that, despite her size, they would have been able to move her working as a team. Ana gave evidence that she tried to move Holly but was unable to do so on her own. Only Steeven and Angela had received life support training, which included what the recovery position was, and when it was necessary to be used.

Holly Goodchild passed away from:

1a) Positional Asphyxia
1b) Morbid Obesity and Epilepsy
2) Left Ventricular Hypertrophy