26 April 2018

Before HM Assistant Coroner Mr Heath
Sitting at York Innovation Centre
17 April – 26 April 2018

The inquest into the death of Danny Tozer, 36, has today concluded with the coroner finding Danny died of natural causes. In the narrative conclusion he did not find neglect, but commented that the communication between Danny’s family, care providers Mencap, and City of York Council who commissioned the care, was not satisfactory. Danny’s family believe the evidence heard at the inquest painted a picture of confused and inconsistent support, with no one person or agency prepared to take overall responsibility for Danny’s care.

Danny was diagnosed with autism, epilepsy and learning disabilities. He was a resident of a supported living home operated by the charity Mencap at Maple Avenue in Bishopthorpe, York. In September 2015 Danny was found unresponsive in his room, and was taken to hospital where he later died. The consultants at the hospital concluded that he had a cardiac arrest, as a result of an epileptic seizure.

Danny was recognised as requiring 24 hour help and support. He had been a resident of Maple Avenue for two years and his care was commissioned by the City of York Council with partial continuing health funding. He was unable to speak and could not leave his home unaccompanied. His family understood that Danny was subject to frequent checks, due to the risks associated with his epilepsy.

During the inquest the Coroner heard evidence from Danny’s parents, Mencap and City of York Council as well as from a range of social care and medical experts. He heard evidence as to the nature of Danny’s care and support needs and the extent to which he ought to have been supervised by the people caring for him, as well as to the circumstances surrounding his death, and the steps taken following it.

The Coroner concluded that the cause of Danny’s death was due to Sudden Unexpected Death in Epilepsy (SUDEP). He identified that communication between Mencap, the City of York Council and Danny’s family was not satisfactory and  he noted the extensive steps that are being taken to assist other families who may be in the same position in the future.

Danny’s parents said: Danny was a much loved son, brother and uncle. He was a fit and healthy young man, diagnosed with autism, epilepsy and learning disabilities. Danny was a people person who enjoyed travel, playing his piano, being active and drinking tea.

In 2013 Danny moved to be nearer us and we were hopeful that he could have a positive and fulfilling life in York.  The evidence that we’ve heard during this inquest paints a picture of confused and inconsistent support; a lack of monitoring; no overall coordination; an absence of leadership; and no one person or agency prepared to take overall responsibility for Danny’s care.

This chaotic care became dangerous for Danny and our concerns went unheeded. In September 2015 he was found unresponsive in his room and taken to hospital where he later died.

Learning disabled people should not die on average twenty years before their non-disabled peers, their deaths frequently un-investigated. We were shocked that we had to fight for two years to get an inquest into the unexpected death of a physically healthy and active 36 year old. We are grateful to Ben McCormack of Garden Court North Chambers and Gemma Vine and Anya Campbell of Minton Morrill Solicitors for their legal representation.

 Danny’s senseless death has devastated his family and friends. He had so much to live for. As his parents we are proud of how Danny approached life. He lit up our lives.”

Deborah Coles, director of INQUEST said: Were it not for this family, Danny’s death would have received no scrutiny. Such public scrutiny is vital for local and national learning and safeguarding lives in the future. He died in the care of Mencap, a charity which describes itself as the ‘leading voice’ for those with learning disabilities. It is astonishing therefore that Mencap both failed to carry out an investigation into Danny’s death and were not prepared to support Danny’s parents’ requests for as full and thorough an inquiry as possible.

Currently, the inquest and investigation systems are failing to consistently and effectively shine a light on issues leading to the widespread premature and unexpected deaths of people with learning disabilities. We need clear guidance for coroner’s on in depth Article 2 inquests in these cases, and decent investigations with the involvement of bereaved families, in order to build national oversight and encourage much needed policy and cultural change.”

Gemma Vine, Head of Civil Liberties and Solicitor for the family from Minton Morrill: “Danny’s family have been failed numerous times by different organisations over the years not just in the lead up to Danny’s death but also following it. If it wasn’t for their tireless efforts in convincing the Council to commission an Independent Report and obtaining legal advice there wouldn’t have been an Inquest and the apparent failings identified during the evidence given at the inquest wouldn’t have been brought to light. This is a prime example of why families in this position should be granted Legal Aid without being means tested to ensure that they are properly represented from the very start.”



For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or here.

INQUEST has been supporting the family of Daniel Tozer since 2015.  The family is represented by INQUEST Lawyers Group members Gemma Vine of Minton Morrill Solicitors and Ben McCormack, Garden Court North Chambers.

The interested parties represented at this inquest are:

  • Danny’s Family
  • City of York Council
  • Mencap
  • York Hospital
  • Care Quality Commission
  • NHS Clinical Commissioning Groups

The inquest was live tweeted throughout by activist and campaigner for open justice, George Julian at twitter.com/TozerInquest


Premature deaths of people with learning disabilities:

  • People with learning disabilities have poorer health and shorter life expectancy than those without. The latest statistics from NHS digital found that males with learning disabilities had around a 14 year shorter life expectancy than the general population.
  • Epilepsy is more common in people with a learning disability than in the general population. About 1 in 3 people (32%) who have a mild to moderate learning disability also have epilepsy. The more severe the learning disability, the more likely that the person will also have epilepsy. (Epilepsy society)
  • 42% of deaths of learning disabled people are considered to be premature, and over a quarter are amenable to better-quality healthcare, found the first largescale inquiry of its kind published in 2013, The report of the Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD).