Edward Ramsay acted for Michael’s family at the inquest into his death, which resulted in HM Senior Coroner for Buckinghamshire returning a conclusion of unlawful killing – thought to be one of the first instances post the Supreme Court decision in Maughan when such a conclusion has been reached where the death occurred in a care home setting.

Michael suffered from advanced dementia and was a known choking risk. He was a resident at Hampden Hall Care Centre (run by Westgate Healthcare). Following a choking incident in July 2019 he was assessed by SALT and placed on a strict feeding regime of only pureed food. In late October 2019 he was provided with a ham sandwich by a permanent member of the night shift team and choked to death. The evidence at the inquest determined that Michael had been fed sandwiches on multiple previous occasions in contravention of his care plan.

Following a number of Pre-Inquest Review Hearings HM Senior Coroner concluded the hearing of evidence on 23 February 2023. Thereafter he received detailed written submissions as to whether there was sufficient evidence to leave safely to himself (applying Galbraith plus) a conclusion of unlawful killing, on the basis of gross negligence manslaughter committed by the carer who fed Michael the ham sandwich and/or corporate manslaughter (under s.1 of the Corporate Manslaughter and Corporate Homicide Act 2007) in relation to senior management failures at the care home that had caused or contributed to Michael’s death. In a detailed and considered ruling delivered on 9 March 2023 (see below) he determined that the test for gross negligence manslaughter on the part of the carer had been met on the balance of probabilities, but not the offence of corporate manslaughter.

Ed was instructed by Lynda Reynolds (lead Partner for inquests at Hugh James).