A report by HASCAS commissioned by the NHS Oxfordshire Clinical Commissioning Group has ruled that care home staff’s failure to coordinate care effectively was one of several factors that lead to the death of 23-year-old Nico Reed in an Oxfordshire care home.

Nico had cerebral palsy, learning difficulties, and was a wheelchair user, resulting in him requiring a high level of care. The report notes that Nico’s transition from school into an adult placement was rushed, and equipment he required was not readily available at Barrantynes, the care home in which he was placed. Nico’s parents were unhappy with the standard of his care, as the rushed nature resulted in a lack of proper training for staff.

Nearly two years later, the equipment he required was still not available, resulting in his needs being still not properly met. This was compounded by the lack of funding, which would have been available to Nico has the correct applications been made, the failure to coordinate his care, and the failure to correctly assess his mental capacity. Staff were also not trained to deal with emergency situations, leading to a 20-minute delay in calling an ambulance once Nico was discovered to be in danger. The care home also lacked equipment to aid if patients aspirated, in spite of Nico being a known risk.

However, the report said stated that it was not certain if Nico’s death could have been prevented, a statement which his family strongly dispute.

In a statement within the report, Nico’s parents said that they were made to feel that their son’s death was unimportant, and that he had been quickly forced to move Nico into an adult care home as he was being removed from his boarding in Penhurst School “to save money,” which social services were transparent with them about.

They concluded their statement, saying that “perhaps the most tragic aspect of this story is that once there was a happy family with a happy, smiling son.

“Our beloved son is dead and we are changed forever.”

The report in its entirety can be read here.

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