Lyn needed around the clock care after sustaining a brain injury at birth. She had very limited communication.
The care home dialled 999 but because of the information given to the ambulance service, Lyn was categorised as non-urgent. She was eventually taken unaccompanied by ambulance to Kingston Hospital on 15th January, having been left lying on the floor for three hours with fractured ribs and arms. She was discharged back to the home later that day having been diagnosed only with a fracture to her right arm.
During the morning of 16th January, her health seriously deteriorated and she went back to the hospital where she was found to have much worse injuries over her whole body, including a left arm fracture, broken ribs and aspiration pneumonia. Lyn died on 25th January.
In written evidence presented at the inquest, Lyn's treating A&E doctor admitted he 'should have' arranged a trauma CT scan and, had he done so, Lyn would have been admitted to hospital that evening.
A Safeguarding review conducted by the London Borough of Richmond found neglect on the part of the residential care home, run by Certitude.
Following the inquest, Kim Parker told the press that her feelings of betrayal and anger at the people meant to be caring for her sister have not abated in the two years since she died.
'My job right now is to speak up for everyone with vulnerable relatives in care to demand that they are treated properly and fairly," Kim said. "These terrible failings must not be forgotten or glossed over, and promises kept that things will improve. They have to, or Lyn will simply become another statistic, and that would be unbearable.'
Caron Heyes, representing the Parker family, said that the evidence at inquest had been difficult to hear.
'Lyn was the tragic victim of catastrophic failures of care that were simply not acceptable and caused her avoidable death. No one wants to be in a care home, but you have to know it is safe. To hear that the most vulnerable can be treated so carelessly should appal us all.
'We cannot go on and on hearing about failures to protect people with learning disabilities from avoidable errors in care. It is up to the institutions involved to listen, learn and to keep their promises to ensure people in their care are safe.'
Caron Heyes leads a pro-bono project called Rachel's Voice between Fieldfisher and Mencap to raise awareness of inequality in the healthcare system of people with learning disabilities, focusing on reducing the numbers of deaths caused by avoidable mistakes in medical treatment. Importantly, Caron was successful in having the term 'learning difficulties' as a cause of death removed from Lyn's death certificate. This is important since a learning difficulty is never a cause of death.
Caron previously represented the family of Rachel Johnston who also had learning difficulties. Rachel died from hypoxia after having all her teeth removed, while the care home where she lived failed to notice her deteriorating condition. The coroner concluded neglect contributed to Rachel's death, with the finding that she was discharged with inadequate information, and a gross failing of the care home to provide basic medical care, causing her to suffer a cardiac arrest and later die.
This case echoes previous cases where focus on the learning disability rather than on relevant clinical factors, or a lack of accommodation of need, contributed to care failures, or where appropriate equipment and treatment were not provided, or patient concerns about their health were not investigated.
Subsequently, Caron and Mencap launched the Rachel's Voice campaign to highlight serious inadequacies in the care given to people with learning difficulties.
Sign up to our email digest