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Coroner raises serious concerns with Surrey County Council following Jake Baker inquest

A coroner has written to Surrey County Council and the Care Quality Commission raising concerns that a rigorous review of the circumstances that led to the death of Jake Baker has not been undertaken by the council, nor has it taken steps to avert the risk of future deaths.

Posted on 22 February 2024

In December 2023, an inquest concluded that neglect arising from a catalogue of failures by Surrey County Council and Ruskin Mill Trust contributed to the death of the 18-year-old. The cause of death was recorded as diabetic ketoacidosis.

The Assistant Coroner for Surrey, Caroline Topping, was satisfied that in the four years since Jake’s death, Ruskin Mill Trust had undertaken an extensive review of their practices to address the concerns that were raised at the inquest.

However, she did not believe that the same was true of Surrey County Council and she has now written a Prevention of Future Deaths report, also known as a Regulation 28 report, identifying matters of concern.  

In the report, she said the issues surrounding the inadequacy of Jake’s pathway plan had not been addressed comprehensively, training is not mandatory and is only now being rolled out. She added that the court was not provided with copies of the training provided to personal advisers so she could not be assured of its adequacy or its implementation.

Other concerns included:

  • The process for getting a learning disabilities diagnosis remains opaque. There is no protocol and those making decisions in relation to young people can struggle to obtain vital information.
  • How people can access the numerous adult social care teams to obtain adult social care assessments for care leavers, which  leads to confusion and delays. Vulnerable care leavers are at risk of being denied necessary support.
  • How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions.
  • Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs.
  • Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit as to the effectiveness of the mandatory training provided and how it is being used in practice, meaning there is a risk that flawed assumptions regarding capacity will continue to be made.

Surrey County Council is under a duty to respond to the coroner’s concerns within 56 days of receiving their report. In their responses, they are required to set out the action taken, or proposed action, including a timetable or to explain why no action is to be taken. 

Jake, who also had learning disabilities, died on 31 December 2019 while visiting his family home in Woking. It was the first time he had visited his parents for longer 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. 

Jake had been living at Ruskin Mill College, 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, for 15 months. 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. 

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. 

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.

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

“Sadly this is not the first time that the a Coroner has made a report to Surrey County Council regarding issues with their social care provision for children and young adults.

“What is of real concern is that four years after Jake’s death, Surrey County Council has only recently started to look at the deficiencies in the care and support it is providing young people such as Jake, which is putting lives at risk. The Coroner heard evidence from a number of witnesses at Surrey County Council and remained concerned that they are not doing enough put things right and make care provision safe. At present, vulnerable care leavers are being denied necessary support and Surrey County Council is showing no urgency to improve the situation.

"I hope for Jake’s family and others out there who are not getting the support they need, that Surrey County Council takes urgent steps to ensure its staff are aware how to meet the legal obligations it has towards vulnerable children and young adults in their care and to those leaving care.” 

Anna Moore
Court of Protection Human rights Inquests Judicial review

Anna Moore

Anna Moore is a partner in the human rights department.

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