Failures by Surrey County Council and Ruskin Mill Trust contributed to death of 18-year-old diabetic student Jake Baker

Jake, who also had learning disabilities, died on 31 December 2019 while visiting his family home. It was the first time he had visited his parents for more than two nights since he was placed in the care of the Surrey County Council when he was eight years old. 

He arrived home on Christmas Eve, became unwell on 28 December and was found unresponsive in the early hours of 31 December by his mother and stepfather who had thought Jake was suffering a tummy bug. Neither they nor Jake had been trained to recognise or seek medical advice for a deterioration in Jake’s diabetes. 

The cause of death was diabetic ketoacidosis. 

Coroner Carolyn Topping said Jake’s death was avoidable and if he had been admitted to hospital any time before 5pm on 29 December he would have been successfully treated. 

At the conclusion of the Article 2 inquest she issued a list of failures by Surrey County Council and Ruskin Mill Trust that contributed to Jake’s death. 

The coroner said there was a systemic failing on the part of Surrey County Council to adequately train and oversee personal advisers about their legal obligations in preparing pathway plans for children leaving care. 

She said Ruskin Mill Trust failed to ensure Jake’s safety when he went home for contact with his family. 

Jake had been living at Ruskin Mill College for 15 months, a residential college in Stroud run by Ruskin Mill Trust, a charity that provides specialist education for young people with learning difficulties and special educational needs. Before then, Jake had been resident at Burbank children’s home in Woking where he was diagnosed as diabetic at 13 years old and coeliac at 14 years old. 

In the years Jake had been at Burbank, the children’s home took responsibility for his care and his family saw him around four times a year for supervised visits. They were given regular updates about his care and progress from his keyworker. 

However, when Jake moved from Burbank to Ruskin Mill College the family were told this was his “road to independence”. Jake’s stepfather told the inquest that the family had little contact with the college staff except when looked-after child reviews were due. Jake kept in regular contact with daily FaceTime calls and his family said they loved to hear his news. 

After Jake turned 18 in 2019 the family were told Jake could visit his family alone as often as he liked, and he visited four times during that year. It was the first time the family had experienced unsupervised contact. Until December 2019, Jake did not stay at home for more than two nights.

When the visit was arranged for Jake to stay with his parents at their home in Woking for Christmas 2019, no instructions were provided for his diabetes care. Jake’s mother and stepfather were told that since Jake was 18, he could handle the necessary care himself.

Only a week before Jake was due to travel home, his family heard from Jake that he had moved to Glasshouse College, a different residential college in Stourbridge also run by Ruskin Mill Trust. 

Jake’s parents were careful to give Jake only gluten-free food during his stay and believed Jake was monitoring his blood glucose levels and administering his insulin himself. He had been given sufficient insulin for his seven-day stay to 30 December. However, on the night of 28 December Jake began to feel unwell. On 29 December he vomited and was nauseous. It is believed Jake he took his last dose of insulin on that morning. 

The inquest noted that overnight from 28 to 29 December Jake developed diabetic ketoacidosis as a result of hyperglycaemia in the preceding days and should have had immediate hospitalisation. 

Jake was too unwell to return to college in Stourbridge on 30 December. His mother thought he was ill with the same tummy bug affecting his brother and called the college to inform the Team House Manager. When a staff member telephoned Jake’s phone later that day, Jake was too ill to take the call. 

The staff who were travelling to collect Jake were told to return to the college. His family was not told to take him to hospital, noted the coroner. 

At 11pm on 30 December, Jake’s family saw him sleeping, but at 3am when his mother went to check on him, he was unresponsive. An ambulance was called, and paramedics told Jake’s parents that he had died. 

Following Jake’s death an investigation into the support provided by Ruskin Mill Trust found there had been a breach of Care Quality Commission regulations to safeguard adults.  Transform Residential Limited, the body responsible for providing care services to Ruskin Mill Trust, was found to have been criminally liable and was fined.

Jake's former teacher Hilary Armour was an Interested Person at the inquest into his death. She told the court that Jake's transition from school to college was not handled well. 

The coroner said Jake lacked the ability to be wholly independent in managing his diabetes. He was not given any information about the dangers for him to have unsupported contact if his blood sugars became imbalanced. He was not trained to manage his diabetes if he became unwell. No capacity or risk assessment was made about Jake’s ability to make a decision to go home unsupported for two days. No minutes were taken of Jake’s final looked-after child and pathway planning meeting on 27 March 2019 at Ruskin Mill College. No note was made of family contacts. Jake’s family were not given any advice at any stage on how to keep him safe if he became unwell nor given any emergency contact numbers. They were not given any training in diabetes management nor told about the symptoms which might suggest he needed immediate medical attention. 

Ms Topping said those involved in making decisions for Jake from the Surrey Care Leavers team and Children’s Services failed to ensure Jake’s safety when he went home for overnight contact from March 2019 by failing:

• to obtain information about the risks posed by type 1 diabetes from specialist diabetic services.
• to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently.
• to undertake a risk assessment in relation to his ability to manage diabetes independently.
• to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family.
• to co-ordinate the agencies providing support for Jake to inform the pathway plan. 
  properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family.
• to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family.
• to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks.
• to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken.  

Ruskin Mill Trust failed to ensure Jake’s safety when he went home for contact by failing:

• to ensure that any employees involved with pathway planning meetings for Jake were fully informed about the extent of the risks posed by type 1 diabetes.
• to risk assess the risk posed to Jake by his diabetic condition when he went home for contact.
• to put in place a care plan informed by his diabetic specialist team, Jake, his family and staff.
• to ensure that they were aware on a daily basis when he was away from the college what his blood sugar readings were. Had they done so they could have ensured admission to hospital at the latest by the morning of December 29, 2019.
• to establish the nature of his condition when notified that he was unwell on the 30 December 2019.

Jake’s family said: 

“Losing Jake has been incredibly difficult for our family, especially as he died in our home at what should have been a happy time. We trusted Ruskin Mill Trust with Jake’s care, and we have been let down by them in the worst possible way. 

“Jake was an enthusiastic and determined young man who always put his mind to things. He was happy to help out in the garden or with DIY. He had a kind soul and would get very excited when meeting new people. He loved dogs and playing pranks on his brothers and sisters. 

“Jake wanted to be more independent and was keen to learn but to anyone who met him it was clear that he needed help, particularly in handling his diabetes. Before Jake turned 18, he had a key worker that we trusted and who he had a great relationship with. We were able to spend time together as a family safely, knowing that Jake was well supported by the staff at Burbank children’s home. 

“This changed when Jake moved from Burbank to Ruskin Mill College. We were told it would be his road to independence and from this point on we didn’t have much contact with the people who were supposed to be supporting Jake. We were never made fully aware of how severely his diabetes could affect him, or how he should be managing it. As a family we did all we could to make sure that Jake was looking after himself and was well taken care of, but those that were put in charge of his care didn’t give us the information necessary to ensure Jake’s safety. There is nothing that can take away the pain of losing Jake, but it is our hope that lessons will be learned from his death so that another tragedy is prevented.” 

Leigh Day partner Anna Moore, who represented Jake’s family, said: 

“The Coroner’s detailed investigation and critical findings illustrate a catalogue of failings that led to Jake’s death. Jake’s family welcome these conclusions and hope that lessons will be learned from his death. What is particularly important is that those authorities entrusted to look after children and support them through their transition to adulthood are doing so properly.

"The evidence heard at the inquest showed that no one with current responsibility for Jake had a clear picture of needs and what support he required. Very worryingly, those at Surrey County Council who were meant to be supporting Jake into his transition to adulthood were not aware of the scope and extent of this important role. This needs to be urgently addressed so that children and young adults, and particularly people like Jake with additional needs, are given the support they need when they turn 18 and beyond.”