A “profoundly disabled” care-home resident who was left alone for hours waiting for an ambulance died in hospital days later.
Darren Walker, 55, lived at Sue Ryder’s neurological care centre, The Chantry in Ipswich, from January 2020 until his death at Ipswich Hospital on November 29, 2022.
Mr Walker suffered a traumatic brain injury in a 2008 hit-and-run and later developed epilepsy. He lived independently for 11 years before his deteriorating health forced him into care, leaving him with “profound disabilities”.
His family told the inquest staff lacked time to support him properly and raised concerns about his medication and care. They said his room was cold because the windows would not close, mould covered the walls, and he was sometimes found with dried vomit around his mouth and on his bedding.
The Sue Ryder organisation has since admitted his care was "not good enough".
Coroner Darren Stewart OBE previously identified “systemic failures” in the home’s record-keeping and criticised its conduct during the inquest.
Brainkind took over The Chantry in 2023. The charity announced in 2025 that it would leave the Grade II-listed building in April 2026 because bringing it up to modern standards would cost millions of pounds.
Days later, claims emerged that residents had been left on mattresses in the car park after a fire drill.
On the inquest’s final day, Monday, Mr Stewart outlined the events leading up to Mr Walker’s death.
He had a GP appointment on November 16 and was prescribed antibiotics for a urinary tract infection (UTI).
At about 5.20am on November 21, Mr Walker was checked by a nurse who questioned why his antibiotics did not seem to be working.
Records showed that Mr Walker was not checked again for six hours. Staff called an ambulance at 11am after noticing he was still deteriorating.
He was left alone in his room while waiting for an ambulance, which arrived at 2.43pm. The 999 call was wrongly categorised because of “human error”, delaying help.
Mr Walker was taken to Ipswich Hospital, where he died days later; a pathologist gave aspiration pneumonia as his cause of death, but expert witnesses questioned whether he had sepsis.
Mr Stewart said there was evidence of failings in Mr Walker’s care, but not enough to establish neglect.
Mr Stewart said he would have issued a Prevention of Future Deaths report if Sue Ryder still provided this type of care.
Mr Stewart said he would write to the Care Quality Commission asking why concerns about The Chantry had not prompted another inspection, and to the Nursing and Midwifery Council about nursing failures identified at the inquest.
Safeguarding concerns were raised at the centre earlier in 2022 and again after Mr Walker’s death, with both incidents investigated by police.
“Mr Walker was a vulnerable person – perhaps an example of one of the most vulnerable people in our society,” said Mr Stewart.
He recorded a narrative conclusion summarising the facts of Mr Walker’s death.
A spokesperson for Sue Ryder said: “We thank the coroner for this thorough inquiry, which we have fully supported and helped with at each stage. At the heart of this is a grieving family and we want to offer them our condolences.
“While we no longer manage The Chantry, the care Darren received in 2022 was not good enough and fell below the standards that we pride ourselves on. We would like to extend our apologies to Darren’s family.”
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