Before Senior Coroner David Reid, Worcestershire Coroner’s Court
24-30 May 2023

Sally Lewis died on 27 October 2017, aged 55. She died of large bowel obstruction as a result of fecal impaction. This followed Sally having suffered chronic constipation for many years. It has transpired that there were significant problems with Sally’s care in the months and weeks leading to her death, following her having moved to The Dock, a placement run by Dimensions UK Ltd, in 2016.

An inquest into Sally’s death took place from 24–30 May 2023, following a delay of several years after the Care Quality Commission’s decision to prosecute Dimensions UK Ltd for failures related to Sally’s constipation. That prosecution was brought out of time, and so no further action has been taken in the criminal courts, leaving matters up to the Coroner to investigate. 

After hearing from Sally’s carers, managers at Dimensions, a safeguarding investigation officer at Worcester County Council, and expert gastroenterologist Professor Ian Gilmore, the Coroner found:

• Sally was prescribed appropriate medication for her constipation since at least September 2016
• Despite that, Sally had not been given her Laxido medication since December 2016 (so received none of this medication for the ten months prior to her death)
• The reason for the failure to give her Laxido medication was because there was no proper or adequate regime in place to monitor and record Sally’s bowel movements
• There ought to have been a plan in place to monitor and record Sally’s bowel movements so her carers could use their judgement to know when to administer Laxido
• None of the support workers looking after Sally had any proper or adequate training on constipation or bowel issues
• Had staff had such training, then staff would have realised how important it was to monitor and record Sally’s bowel movements
• If Sally’s support workers encountered difficulties in monitoring and recording Sally’s bowel movements, they could and should have raised the issue with the Dimensions locality manager and operations director, and Sally’s GP
• Had a proper regime to monitor and record Sally’s bowel movements been in place, either sufficient Laxido would have been provided to relieve Sally’s constipation or further advice would have been sought via Sally’s GP
• Had a proper regime been in place to monitor and record Sally’s bowel movements, Sally probably would not have died when she did

The Coroner found that this amounted to a gross failure to provide or procure basic medical care for Sally, and that neglect contributed to Sally’s death.

Julie Bennet, Sally Lewis’ sister, and Bindmans LLP’s client, said:

We have fought and struggled as a family for nearly six years to try and find out the truth of what happened to Sally. She was a beautiful person who brought joy and a love of life everywhere she went. Sally died unnecessarily because those who were meant to keep her safe decided to stop doing basic checks to ensure she was well. It has been heart-breaking listening to it at all, because the evidence has been much much worse than we could have expected even after six years of reading it on paper. The only relief has been that someone – the Coroner – has listened and ensured that we now know how badly Sally was failed and neglected.  

When we first started trying to get answers about Sally, it took three years and a new Coroner for an inquest to even be opened. There are many other families who lose their loved ones with learning disabilities who never get this far and so many more learning disabled people who pass away and don’t have a sister or someone else to fight their corner after they’re gone. Even having now got answers about Sally’s tragic death, we cannot help but think of all the other deaths which happened before Sally died and those over the last six years which could have been prevented. 

If the changes implemented since Sally died save one life, even though Sally can never come back to us, the fight will have been worth it. We are finally able to grieve.

Will Whitaker of Bindmans who represents Julie Bennet, comments:

Sally died in horrific circumstances. In basic terms, she died of constipation. This was a long-standing condition, which had – in the past – been managed by those who were charged with her care. After moving to The Dock, Sally was let down. No one knew that things were getting worse for Sally because there was no adequate regime in place to monitor her condition. The result was that Sally died. Had there been very simple steps taken – such as monitoring when Sally had passed a bowel motion, or checking when she had last had her Laxido – Sally’s death may have been avoided. 

This should be taken as a stark warning to all those in the care sector to ensure that they listen and make sure that the health needs of people with learning disabilities are properly monitored, reviewed, and considered.

Sally Lewis’ sister, Julie Bennet, is represented by Will Whitaker of Bindmans LLP and Stephen Clark of Garden Court Chambers.