Rose Harvey-Sullivan secures finding of neglect in inquest relating to death of disabled man in nursing home

7BR’s Rose Harvey-Sullivan represented the family of Joel Ettorre, a young man with profound physical and learning disabilities, and the inquest into his death in June 2025. Joel was known by many as ‘Smiler’ due to his cheerful nature; he had a love of the TV show Friends and had enjoyed a happy life living at home with his family.

Joel died in 2016 during a short two-night respite stay in a nursing home. There were extended criminal investigations into whether the company that ran the nursing home and/or individual nurses should be prosecuted for gross negligence manslaughter in respect of his and several other deaths in homes owned by the same company, all of which delayed the coroner’s investigation.

The inquest, heard between 17 and 25 June, heard that Joel’s PEJ tube (with which he had been having problems) had probably become displaced early on during the respite stay, and despite showing clear signs of worsening health and distress, nurses failed to take any action to investigate or seek appropriate medical attention. Joel rapidly became extremely unwell and died of intra-abdominal sepsis at the nursing home on the second morning of his stay. Witnesses told the court of unsafe staffing levels, how earlier complaints made about the nurses involved had been ignored and later found stuffed into managers’ drawers, and how there was no working blood pressure monitor in the home at the time of Joel’s death, such that staff could not even take basic observations.

Rose made submissions at PIRs that a nursing expert was essential in this case; ultimately, as one was not retained by the court, Rose obtained instruction to disclose the nursing report obtained for the linked civil proceedings, which – whilst opposed by the other IPs – the coroner admitted into evidence. The expert provided significant and compelling evidence with regard to the poor standard of care Joel received.

The court found that Joel’s death was wholly unavoidable, and that had staff acted upon the clinical signs and symptoms that they had recorded in his notes by taking him to hospital in a timely manner, he would on the balance of probabilities have survived. The court found that the failures and inaction of the nursing home company, as well as the two nurses in charge of his care in the 24 hours prior to his death, amounted to neglect.

The court further found that neither nurse showed any awareness or insight into the consequences of her treatment of Joel. Rose invited the court to write to the NMC to make its concerns known as a matter of urgency (neither nurse’s ability to practice was currently restricted); the court agreed to do so.

Rose has a particular interest in inquests and civil claims relating to deaths of individuals with disabilities; there is comprehensive evidence that there is a higher prevalence of avoidable deaths amongst this population group (see e.g. the LeDeR reports produced on behalf of NHS England). It is particularly important that accountability is achieved for individuals who are often more vulnerable, who require additional – rather than less – care and support, and who may not have been able to voice their needs for themselves.

Rose was instructed by RWK Goodman Solicitors. The nursing home company was represented by Simon Antrobus KC.

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