Coroner describes actions of nine-year-old's carers at the time of his death as “chaotic”

Arin Yarkin died on 20 August 2023 after he was found to have stopped breathing on a minibus taking a group of children on an activity trip during a respite care weekend at the Discovery Home in east London.

When the minibus stopped at a petrol station to re-fuel, around an hour into the journey, a carer noticed that Arin appeared to have stopped breathing, and the shift leader called 999. Following the 999 call, paramedics arrived and carried out CPR on Arin before he was taken by ambulance to Queen's Hospital, Romford, where his death was confirmed.  It is unclear how long Arin had been in cardiac arrest before it was noticed by the carers. 

Arin, who had a diagnosis of quadriplegic cerebral palsy, severe dystonia and other symptoms of developmental delay linked to his premature birth, was on his first ever weekend away from his family at the time. He primarily lived at home with his parents and older sister and attended Stephen Hawking school in Tower Hamlets. 

Concluding the inquest, which was held at East London Coroners Court in Walthamstow from Tuesday 1 to Friday 4 September, Senior Coroner Graeme Irvine found that Arin died from natural causes including bronchopneumonia and cerebral palsy, adding that: 

• The actions of staff caring for Arin at the time “were chaotic”. 
• There were attempts to check on Arin during the outing but the response when it was determined that something was wrong had “a chaotic element to it”. 
• CPR was probably started on Arin by carers on the minibus, but it was unclear how long it had continued for.  
• The evidence of one carer was particularly unclear as to whether she saw any CPR carried out and her answers were “confused”. 

During the inquest, a recording of the 999-call made by Arin’s carers was played in which the call handler repeatedly asked the shift leader to start CPR, and to get Arin flat on his back on the ground. During the call, there was no indication from the audio that CPR was commenced, nor that attempts were made to get Arin out of his wheelchair onto a flat surface. 

Evidence heard from London Ambulance Service paramedics who attended the incident stated that no carers were performing CPR when they arrived on the scene. In contrast, evidence given by some of the carers from Discovery Home maintained that the shift leader was performing chest compressions to Arin in his wheelchair whilst the 999 call was ongoing. It was accepted during the inquest that, in any case, it was incorrect and ineffective to perform CPR on a patient in a wheelchair, as they need to be lying on a flat surface. 

In closing submissions, the family raised concerns about the consistency and credibility of the evidence provided by the carers at Discovery Home, arguing that statements were at times inconsistent and did not appear to reflect a significant amount of learning since this tragic incident. 

Evidence was heard from forensic pathologist and respiratory paediatric expert that for children with cerebral palsy, infections such as bronchopneumonia can appear to progress more quickly than for other children, as they may have difficulties clearing their chest, and may have lower physiological reserves. In addition, as Arin was non-verbal, he was unable to express any discomfort or pain, meaning his infection progressed without staff noticing. 

Evidence heard during the inquest was that Arin did not eat well at several meals during the weekend of 18-20 August, but this was not picked up in any handovers. On the night of 19-20 August, he woke up four times during the night, which was unusual for him, and on the morning of 20 August, he was sweating more than usual. Staff did not take Arin’s temperature or perform any clinical observations, nor did they consider that Arin might be unwell. They did not contact Arin’s mother, nor did they seek medical advice. 

The inquest heard how an independent investigation was carried out following Arin’s death, which identified several key areas of learning for Discovery Home. The coroner concluded that the recommendations of the report did not seem to have been passed down from management to the carers who are involved in the day-to-day care for children. 

The coroner has indicated that he is considering writing a Prevention of Future Deaths report to Discovery Home, which is operated by The Qalb Short Break Services Ltd, and Ofsted regarding his concerns that the staff at Discovery Home have not recognised or embraced the lessons to be learned from Arin’s death.  

A Prevention of Future Deaths report may also be written to training provider Caring for Care, who trained some of the carers at Discovery Home, over concerns that erroneous advice was given that it was acceptable to perform CPR on a person in a wheelchair. 

Arin's parents are represented by solicitor Tiffany Bucknall at law firm Leigh Day and Michael Etienne of Garden Court Chambers. 

Speaking after the inquest, Arin’s mother Berna Mazici said: 

“It has been just over three years since we lost our beautiful Arin - a deeply loved boy whose warmth and smile touched everyone who knew him. During this time, we have felt unable to find closure or even begin to properly grieve because we have been left with so many unanswered questions.  

“Arin had quadriplegic cerebral palsy and global developmental delay. He was non-verbal and relied entirely on those caring for him to recognise when something was wrong. His complex medical needs meant that he could become seriously unwell very quickly and require emergency medical treatment. 

“We remain concerned about whether staff caring for children like Arin have sufficient training to recognise their individual health and communication needs, and whether clear, individual emergency plans are in place when a child becomes unwell. 

“We are particularly concerned by the conflicting evidence heard at the inquest about whether CPR was commenced on Arin. The evidence was that, for CPR to be carried out effectively on Arin, he would have needed to be removed from his wheelchair and placed on a firm, flat surface. However, evidence was given that CPR was carried out while Arin remained strapped in his wheelchair. 

“We have never approached this inquest looking to blame anyone. We wanted answers, and we wanted to know that lessons would be learned. But despite all the evidence heard at this inquest, important questions remain for us. Not least, the deeply troubling question about what happened in those critical moments when Arin needed emergency help, and whether staff had the appropriate training and confidence to respond to the situation. 

“Nothing can bring Arin back. But he mattered, and his life mattered. We hope that the lessons from his life and his inquest will lead to meaningful change, so that other vulnerable children are understood, properly cared for and kept safe, and to help prevent another family experiencing a tragedy like ours.” 

"On Friday, we entrusted our happy, smiling boy into the care of his care home, trusting them to keep him safe and expecting him back through our front door on Monday. Instead, on Sunday, our beloved son died. Arin never came home. No parent should ever have to send their child into the care of others and be left facing the unimaginable reality that they will never see them return back through the door." 

The family’s solicitor, Tiffany Bucknall from Leigh Day said:  

“The evidence heard at Arin’s inquest this week has raised important issues around the standard of care provided children with complex needs in a respite care setting, in particular for those with quadriplegic cerebral palsy.  

“In the family’s view, evidence at this inquest has shown that staff at Discovery Home were ill equipped to identify signs of Arin being unwell, or to deal with an emergency situation. In their view, there were many factual discrepancies between the different accounts of the carers, which were difficult for them to hear. The inquest has also highlighted gaps in reflection and learning from the carers involved in this tragic incident. 

“The family are grateful that the coroner is considering writing a Prevention of Future Deaths report to be sent to Discovery Home and Ofsted, and hope that management at Discovery Home reflect on the evidence and take steps to ensure no other family has to endure the pain that Arin’s has experienced.”