The inquest heard how Matthew Dale, 43, was left alone at Vancouver House care home, Liverpool (Picture: Google)

A man who had severe learning difficulties and autism choked to death on his own incontinence pad, an inquest has heard.

Matthew Dale, 43, was found dead at Vancouver House care home in Liverpool on December 27, 2020.

The inquest heard he was left alone by his carers, which amounted to gross negligence.

He had been living at the home for nine years and was meant to receive one-to-one care between 8am and 8pm each day.

But it’s claimed he was only given hourly checks during his entire time there.

Matthew would often put inedible objects into his mouth, including his own incontinence pads.

To prevent this, his parents would give him draw-string belts and dress him in a back-to-front onesie. But no such preventions were done at the care home.

Nick Cockrell, representing Matthew’s family, said: ‘There are two potential failures which are capable of amounting to negligence.

There was confusion over the type of care Matthew should have received over a nine-year period (Picture: Google)

‘The first is the absence of any system to prevent Matthew having access to his pad, such as the system used by his parents when he was living with them.

‘The second is that Matthew was left alone, unsupervised at the time he put the fatal pad in his mouth.

‘Matthew was a man with a profound disability which made him incapable of keeping himself safe.

‘He was in many ways more vulnerable than a child because he had a child’s limitations with an adult’s ability to tear bits off his pad and put them in his mouth. It’s a combination of those two things that made him particularly at risk.’

He said the risk to Matthew should have been noticed by the staff, as there had been two ‘near misses’ before.

Mr Cockrell continued: ‘There was a complete misunderstanding between the commissioners and care providers.

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‘The commissioners heard Matthew required one-to-one care. They believed that’s what their funding had secured and what Matthew was receiving.

‘Whereas the hours of care that Matthew actually needed and the hours that were funded were two entirely different concepts.

‘Over nine years, many individuals from two commissioning groups and from the care providers have been involved.

‘There have been multiple reviews and meetings and on all these occasions, there has been a fundamental misunderstanding between what the commissioners think they are buying and what the providers think they are being paid to supply.

‘It’s simply not possible to describe that nine-year history as mere individual negligence.’

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Miss Wheeler, representing Integrated Care Systems, previously Liverpool CCG, said Mr Dale was ‘undeniably vulnerable’ but this alone was ‘not enough to engage Article 2’.

She said: ‘We can see from the Deprivation of Liberty Safeguard (DOLS) reviews that the risks identified (to Matthew) were head banging, hand biting and cramming his mouth during meals.

‘These are repeatedly identified. At no point during any of these reviews, has putting inedible objects in his mouth been identified.

‘In so far as the state has assumed any responsibility to Matthew, that duty would apply to head banging, biting his hands, and cramming his mouth at meal times.’

Mr Pollard, representing the Priory Group, which ran Vancouver House before its closure in 2021, agreed with Miss Wheeler, adding: ‘There is a large area for (the coroner) to consider between anything that may be a failure and anything that amounts to gross neglect.’

The inquest continues.

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An inquest heard he was left alone by his carers, which amounted to gross negligence.