25 June 2021

Before HM Senior Coroner for Norfolk, Jaqueline Lake
Norfolk Coroner’s Court, (remote access for media)
Scheduled 28 June – 9 July 2021

Ben was a 32 year old man with Down’s syndrome who was born and raised in Norfolk. He died in the early evening of 29 July 2020 at the Norfolk and Norwich Hospital, having suffered a cardiac arrest that morning at Cawston Park Hospital.

Ben was a friendly and loveable person who enjoyed swimming and spending time with his dogs. He had lived with his mother for all of his life but, due to her falling ill, had to be taken into care whilst she recovered. Following an incident at the care home, Ben was transferred to Cawston Park Hospital on 8 July 2018. From this point on, he was continually held there under the Mental Health Act.

Ben had sleep apnoea which often resulted in his oxygen saturations dropping at night and him appearing drowsy during the day. On the 9th, 10th and 12th July 2020 Ben was taken to A&E at the Norfolk and Norwich Hospital as a result of low oxygen saturations and breathlessness. He was not admitted to hospital on any of these occasions.

During the early hours of the morning on 28 July 2020, Ben began recording low oxygen saturations, which dropped to 35%. Despite these levels being continually recorded for approximately 24 hours, and Ben presenting as drowsy, an ambulance was not called. At approximately 7am on 29 July 2020, Ben went into cardiac arrest. He was taken to A&E and admitted to the Intensive Therapy Unit (ITU) where he died later that day.

The inquest will investigate a number of issues, including:

  • why Ben’s treatment was not escalated on 28 July 2020,
  • the management of his sleep apnoea, medical investigations into Ben’s symptoms,
  • the justification for Ben’s medication (including the use of the sedative Promethazine),
  • and Ben’s dramatic weight gain in the final year of his life.

There is also evidence to suggest one of the hospital’s carers struck Ben, though this is not likely to form a central part of the inquest.

Cawston Park Hospital formerly closed on 12 May 2021. The hospital had been in special measures since 2019.

Gina Egmore, mother of Ben King said: “Ben’s death has left me absolutely devastated. I looked after him for nearly all of his life and I trusted that Cawston Park would care for him properly when they took him in. However, I’m left with the horrible thought that Ben’s death may have been avoided had he received appropriate care.”

Carl Rix of Fosters solicitors said: “This is an incredibly tragic case which raises serious questions about the standard of care provided by Cawston Park Hospital. There is particular concern about the medication given to Ben, the staff’s decision not to escalate his treatment sooner, and how Ben was able to put on so much weight in the last year of his life. We hope that the inquest will provide answers to these questions and obtain justice for Ben.”

Deborah Coles, Director of INQUEST, said: “Ben was in Cawston Park to receive specialist care and ended up dead. He was in a hospital which regulators had already rated as inadequate and where other adults with care needs had died prematurely. We hope this inquest will ensure serious questions are asked of the local authorities and care providers.”    


For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group member Carl Rix of Fosters Solicitors and Jonathan Metzer of 1 Crown Office Row.

Jeesal Cawston Park, Norfolk & Norwich Hospital, the Care Quality Commission, the Clinical Commissioning Group, Norfolk County Council, Norfolk Safeguarding Adults Review Group and a number of individual clinicians are also interested persons to this inquest, some of whom are legally represented.

The inquest is a hybrid hearing. The court is not open to the press in person, but a request can be made to the court to dial in. Contact the court here.

Cawston Park hospital closed on 12 May 2021, after Care Quality Commission (CQC) inspectors reported the provider who ran the hospital (Jeesal Cawston Park) was "unable to demonstrate improvements".

Joanna Bailey, a 36 year old woman who had learning disabilities, died of sudden unexpected death in epilepsy at Cawston Park in April 2018. An inquest heard she was not checked for two hours that night, despite 30-minute checks being in her care plan. See media release. See these blogs on Joanna by George Julian for more information.