AN INVESTIGATION into a York man’s death after suffering a seizure in supported living accommodation has raised a series of major concerns.

An independent review was ordered by City of York Council into the circumstances surrounding the death of Danny Tozer on September 22, 2015, at York Hospital, a day after he suffered an epileptic fit at a house in Bishopthorpe run by the charity Mencap.

The review reported that Danny, an autistic man of 36 with a severe learning disability and uncontrolled epilepsy, had a seizure in his bedroom while the door was shut, followed by a cardiac arrest and brain damage.

It said his parents, Rosemary and Tim, believed it was a preventable death, which had come after they had raised many concerns about the quality of his care, which was commissioned by the council and the NHS.

Mencap said Danny’s death had been a tragedy and it was working on improving its service delivery. It said Mencap had shared all the information it had about the care and support given to Danny with the independent investigator, who had found that its care did not cause Danny’s death.

City of York Council said it had developed an action plan to ensure improvements were made.

In its findings, the review noted there was no immediate investigation by Mencap after Danny’s death, and it was difficult to state with accuracy exactly what occurred on that morning.

However, it identified there were many support plans in place at the home, including ones for the morning routine and an epilepsy risk assessment, but the “actions on the morning of September 21 were not as agreed in Danny’s support plans”. The report added: “Danny was left for longer than he should have been.”

The report also criticised aspects of the care Danny received at the house prior to his death, and the way his parents were treated when they tried to engage with support staff or raise concerns with managers at Mencap and the council about supporting Danny effectively and keeping him safe.

It added: “Danny’s parents reported feeling distressed by an undercurrent of hostility or irritation on behalf of a few staff at (the house). The analysis of documentation presented to this reviewer reinforces and reflects this perception.”

The report said the support provided at the house did not fully meet or satisfy Danny’s needs, sometimes resulting in Danny displaying “frustration and agitated behaviours”.

The report drew attention to Deprivation of Liberty safeguards and codes of practice under the Mental Capacity Act, which should have applied to Danny, saying these were not consistently followed. It said these should “be addressed as a matter of urgency to ensure they are robust and appropriate”.

It recommended a “truly person-centred’” approach should be adopted when assessing individuals’ needs with the intention of commissioning placements, and the council should listen to families’ concerns and take positive and effective action when problems arise.

It said Mencap needed to ensure its systems for supervision, appraisal and training were adequate, and should address the situation where a family had persistent concerns which were not being resolved at a local level.

Danny’s parents said they welcomed the report’s findings and recommendations but felt they had yet to see evidence of the changes required in both organisations to work properly in a person-centred way.

They added that they felt questions remained unanswered about Danny’s death, which would be best dealt with through a formal coroner’s inquest, which Danny deserved.

Mencap said it is working on improving its service delivery and working with families, in line with the report’s recommendations.

The charity’s director of services, John Cowman, said Danny’s unexpected death had been a tragedy and everyone involved in his care had been "deeply upset" by it.

“We continue to extend our condolences to his family, who we have been in regular contact with,” he said.

He said Mencap had shared all the information it had about the care and support given to Danny with the independent investigator, who had found that its care did not cause Danny’s death.

“The report identifies areas of activity we could do better, many of which we are already working on to improve both in respect to the quality of our service delivery and our work with families,” he said.

He added that Mencap was founded by families of people with a learning disability, and the support it provided for more than 5,000 people with a learning disability and their families was at the heart of the organisation.

Martin Farran, City of York Council’s corporate director for health, housing and adult social care, said that with the support of Mr Tozer’s family, it had commissioned the independent review so the local authority and its partners could learn from the tragedy.  “We acknowledge and fully accept the findings,” he said. “Consequently we have developed an action plan to ensure that improvements are made and we’ll continue to work with our providers to ensure best practice.

“We are committed to learning from what has happened and improving practice.”