Patient died as carers watched TV

Black Country coroner Robin Balmain ruled that 22-year-old James Clarke's death was due to neglect and is writing to the Care Quality Commission demanding answers.

Mr Clarke, who was paralysed in a motorcycle accident two years earlier, had a tracheotomy tube fitted to enable him to breathe. The coroner concluded that he died of asphyxiation after the tube became blocked. His carers had checked on him only three times during the night.

Mr Balmain strongly criticised the Willenhall company in charge of his care package, describing their approach as 'profit over performance.' He also reprimanded the Walsall Clinical Commissioning Group, which employed the firm, for not checking that the correct care was being given.

Mr Clarke had been left dependent on round-the-clock care following his accident in March 2009 in Wood Lane, Walsall, when he fell from his bike and slid into the path of an oncoming car. He was 19. After nine months in hospital he returned home to Beatrice Street, Leamore, where he was cared for by his mother Paula with help from carers provided by Complete Care Services in Willenhall.

The women's responsibilities included checking on his comfort and breathing, and changing his tracheotomy tube when necessary. Night-time carers were assigned to him so his mother could sleep. At 10pm on April 4, 2011, Beverley Kent and Mandy Evans arrived to take over from Mrs Clarke who then went to bed. Over the next eight hours the women checked on him at 1am, 4am and finally at 6am when his feeding peg bleeped and they found him dead.

Mrs Evans called the emergency services and gave chest compressions under instruction from the ambulance service until help arrived. However paramedics said that rigor mortis had started to set in and that further resuscitation attempts were useless.

Giving evidence at the inquest, Mrs Kent claimed they had been told by James' mother not to sit in the same room as her son in case they disturbed him. Mrs Clarke strongly rejected this and the claim was dismissed by the coroner as 'unimaginable.'

In her statement to police Mrs Kent said it was 'common practice' to sit in the living room. Mrs Evans told police she was playing on her mobile phone as the two women chatted and watched TV with the volume turned down.

Asked how they would know when the tube required clearing, Mrs Evans said James would cough or give a 'rattling' sound.

Although the tracheotomy tube often became blocked and had to be cleared, carers had only been provided with classroom training but no practical tuition, Mr Balmain was told.

The inquest, held at Smethwick Council House, heard that another firm employed to carry out the training had not been told until the last minute that it was for tracheotomy care, so no notes were handed out or demonstrations given.

Mr Clarke's care package required that he was checked 'throughout the night'.

Mr Balmain was critical of Complete Care Services quality manager Manjit Kaur for not stipulating the frequency of checks.

She took the instruction to mean 'every so often , maybe every 15 or 30 minutes', yet carers were checking James only every two or three hours. Mr Balmain concluded that Mr Clarke's death was due to neglect compounding injuries suffered in the motorcycle accident. He sympathised with the carers, describing their training as 'slapdash' and said 'insufficient attention' was given by Walsall CCG as to what the care company was doing.

His final criticism was for the Care Quality Commission which had assessed Complete Care Services as competent. Mr Balmain said: "They seem to have missed some pretty obvious failings."

Steve Smith, managing director of Complete Care Services, said: "As far as we were concerned, external trainers had signed our staff off as fully trained."