A vulnerable woman named Helen Burnell tragically died in July 2019 after choking on a sandwich that was not properly prepared by her carers. Helen, 60, had lived at Somerset Court in Brent Knoll for 45 years. She was diagnosed with autism, learning difficulties, and Bell’s palsy.
Helen’s death prompted an in-depth review by the Somerset Safeguarding Adults Board (SSAB), which revealed critical gaps in training for care staff, especially those working with autistic individuals. The review followed a Prevention of Future Deaths report issued by the coroner in 2022 after the inquest into Helen’s passing. The coroner recommended improved training about choking risks in adults with learning disabilities and autism.
Helen, who was non-verbal, had lived at Somerset Court since age 15, her care funded by the local council. Her autism often caused anxiety and led her to rely heavily on familiar routines for comfort. By the time of her death, Helen was receiving constant one-to-one care. She had experienced a significant weight loss — one-sixth of her body weight — attributed to increased activity, reduced sleep, and decreased food intake. She also faced medication challenges and sustained an ankle injury from jumping off furniture.
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She was prescribed Haloperidol, a psychotropic medication, but efforts to reduce her medication dosage under the NHS’ STOMP programme (STopping Over-Medication of People with learning disabilities and autism) in 2014 and 2018 failed to improve her quality of life.
Care staff had been instructed to serve Helen only bite-sized pieces of food after speech and language therapists observed she was overfilling her mouth. However, on July 13, 2019, Helen was served a sandwich cut only in half, which led to choking. A one-to-one support worker promptly administered first aid and called emergency services. Paramedics were able to restart Helen’s heart, and she was taken to hospital and placed on life support. With her family’s agreement, life support was discontinued three days later, and Helen passed away.
The subsequent SSAB review involved multiple agencies including Somerset Council, Avon and Somerset Constabulary, and Somerset NHS Foundation Trust, all committed to preventing neglect and abuse of vulnerable adults. The review highlighted difficulties due to Helen’s social worker being based in London, complicating monitoring and reviews. A critical 2018 review did not result in change, as Helen’s family opposed relocation.
Key recommendations from the review emphasize enhanced training for care staff in swallowing and choking risk management, better cross-agency communication, and improved oversight for adults with learning disabilities and autism.
Professor Michael Preston-Shoot, SSAB independent chairman, expressed deep condolences to Helen’s family and stressed the importance of implementing lessons learned from this tragedy. He confirmed that many changes have been adopted and will continue to be embedded as standard practice.
The National Autistic Society, which has managed Somerset Court since the 1980s, decided to close the facility in 2020. The last residents were relocated earlier this year, with plans to sell the land and buildings.