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Failures in adult safeguarding contributed to the death of vulnerable Alzheimer’s sufferer

28 April 2015

The inquest into the death of Ian Sunter has finally concluded today, almost six years after he died, finding that failings in adult safeguarding contributed to the death.

HM Senior Coroner Patricia Harding heard that by the end of his life Mr Sunter had not been seen out of bed for several days, had not eaten for many days, was lying in his own excrement and suffering with multiple serious injuries. Mr Sunter suffered from Alzheimer’s and drank too much alcohol. In the last months of his life, he was socially isolated and although spoke every day to his daughter, Rachel, was too ashamed to tell her about his situation and where he was living. The Coroner found that the evidence was clear that a mental capacity assessment was needed, and that it was "regrettable" that one was not carried out. Mr Sunter was living in supported housing in Sheerness and in receipt of twice daily visits from carers, once daily visit from a housing support officer and under the care of the adult social services at Kent County Council.

Evidence heard by the family indicated carers failed to ensure that even his most basic needs were met in the last week of his life. The police, social services and others involved had proof that Mr Sunter was being physically and financially abused by two women who were thought to be working as prostitutes. They also knew that although he had regularly appeared with serious injuries, he said he was too scared to make a statement to the police against his attackers. The Coroner has found that the failure by Kent County Council to put in place adult safeguarding procedures, and even to have staff who were trained in adult safeguarding procedures, contributed to the death. When Mr Sunter was finally admitted to Medway Maritime Hospital he had multiple serious injuries all over his body, of different ages, including a serious head injury, from which he later died. An independent expert, Mr Kirkpatrick of Addenbrooke’s Hospital, told the Coroner that even when Mr Sunter went into a coma soon after being admitted the situation was salvageable, but he was not transferred to Kings College Hospital, London, for life saving neurosurgery as he should have been.

On receiving the Coroner’s decision, Rachel Sunter, Ian’s daughter says:

“From the moment he died, I have been fobbed off by most of the agencies involved in the inquest. Immediately after his death, I was told by the police that I had to clean his flat, which I did. However, I did not know that they hadn’t taken any evidence from the flat. There was no proper police investigation, and I only started getting information after I made a complaint about the police, but by then, several months later, most of the evidence was gone. With that I lost the chance to find out how my Dad suffered the head injury which later killed him. To this day I believe that he died as a result of being attacked by someone. I will have to live the rest of my life not knowing any more. I felt like I was banging my head against a brick wall, not getting anywhere until I finally got in contact with INQUEST and instructed Bindmans' solicitors. It took almost six years for the inquest to take place. The only reason that a proper inquest has taken place is because I have fought for it. I promised my Dad that I would get justice for him, and that is exactly what I intend to do. The Coroner’s inquest has looked at some of the failings in this case, and she has returned a lengthy and critical conclusion. I intend to continue to fight for justice for my Dad.”

Sara Lomri of Bindmans LLP, Rachel Sunter’s solicitor, says

“This case involves the most terrible catalogue of failings by a number of agencies over several months leading up to the tragic death of Ian Sunter. One of the main difficulties faced by family members in these circumstances is that there is no one avenue that will properly and adequately look at all of the circumstances of the death and ensure that such failings are not repeated. In Rachel’s case, she made a number of complaints to the agencies involved, each variously saying that nothing could be done until the Coroner’s inquest was concluded. Rachel has had to endure an agonisingly long wait for that inquest to conclude. Although Rachel’s wait has been particularly long, unfortunately her experience is not unique, and nationwide families who have lost their loved ones in the most tragic circumstances are currently waiting for many, many months because of the lack of resources available to Coroners to conduct their work. Even then, Coroner’s investigations are relatively narrow, and often leave family members feeling that those involved in the death have not been properly held to account. The system is cumbersome, bewildering and in my experience, often exacerbates a family’s grief at the most difficult time.”

Deborah Coles, co-director of INQUEST says

“The findings of this inquest is another indictment of the treatment of  vulnerable adults by the very agencies who are supposed to be  there to  safeguard them.   The critical findings of this inquest must result in procedures being put in place to address the systemic failures  to  prevent another death in such shockingly distressing circumstances.  No  family should wait 6 year for the inquest into the death of their loved one.  This kind of delay has huge implications for the family and also frustrates the whole  learning process.“


Sara Lomri of Bindmans LLP and Katie Scott of 39 Essex Street are representing Rachel Sunter.

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