Craig Spiby

Private and Confidential  
H.M. Coroner's Office  
Manchester West  
Paderborn House 
Howell Croft North  
Bolton 
BL1 1QY 

18 February 2025 

Thicketford Centre
Thicketford Road
Bolton
BL2 2LW

Tel: 01204 331111

Dear HM Coroner Timothy William Brennand  

Ref: Craig Brendon SPIBY (Deceased) 01844-2024  

Thank you for your regulation 28 report, dated 10/12/2024. Below is our response to all the 
matters of concern identified in the report. 

Background  

Craig Spiby’s death shocked Bolton Cares, in particular the support staff who had directly cared for Craig 
for up to 17 years. Our sincere condolences go out to Craig’s family and he remains in our thoughts.  

Bolton  Cares  is  a  not  for  profit,  Local  Authority  Trading  Company  which  provides  adult  social  care 
services in Bolton, Salford and Wigan and has been doing so since 2016. Bolton Council is our main 
shareholder but we are an independent/separate entity from the Council.  

High standards of quality care are of the utmost importance to us at Bolton Cares and all our staff have 
the right training, guidance and support available to them to carry out their roles effectively.  

Internal Investigation 

Immediately after Craig’s death, I, as the Managing Director, initiated a full review of the circumstances 
that  led  to  his  death  and  we  worked  with  the  police  and  the  family  to  understand  the  situation.  A  full 
review of training records, SALT guidelines, care plans and other relevant documentation was promptly 
undertaken by the registered manager. 

,  who  was 
The  police  on  the  scene,  informed  Bolton  Cares  that  it  appeared  that 
responsible  for  providing  one-to-one  support  to  Craig  on  the  day  of  the  incident,  had  not  followed 
guidelines and may be interviewed under caution.  

The member of staff was immediately suspended pending the police investigation. 

The police later informed Bolton Cares that they were not pursuing criminal proceedings and we were 
able to carry out our own internal investigation.  

During the investigation, we interviewed nine support staff, all of whom supported Craig regularly. This 
included 

. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We analysed training data and the guidelines that were in place and the support and supervision that the 
staff team had received prior to the incident.  

There  was evidence to suggest that  the staff  member  had  not  followed guidance  by a)  not  preparing 
Craig's lunch in line with the guidelines and b) leaving Craig unsupported whilst eating.  

That internal investigation has now concluded and 

 has been dismissed. 

The investigation found that Craig was at significant risk of choking and this risk was highlighted in his 
Support Plan and guidelines. The Support Plans are reviewed and updated regularly, and staff supporting 
Craig had the tools to do so effectively, including the regularly reviewed Support Plans, SALT Guidelines 
and ‘Good day, Bad Day’ guidelines. Staff supporting Craig were familiar with him and his needs and 
would  have  been  considered  experienced  support  staff.  Staff  supporting  Craig  had  received 
recommended training, including First Aid and how to respond to a choking incident and staffing levels 
on the 13th July 2024 were in line with commissioned support hours. 

Safeguarding Strategy Meeting 

On the 10th October 2024 a Safeguarding Strategy meeting was held. The meeting was chaired by Bolton 
Council’s Safeguarding Adults team manager to consider abuse by way of neglect/act of omission. This 
was in relation to the individual carer and not the wider staff team.  Based on the findings of Bolton Cares' 
internal  investigation  and  the  findings  from  the  strategy  meeting  the  allegation  against  the  carer  was 
substantiated. 

Inquest  

I have now had the opportunity to consider the transcript of the inquest proceedings, Bolton Cares had 
been  cooperating  with  the  police  investigation  and  understood  that  all  relevant  evidence  had  been 
provided to the coroner.  

Bolton Cares was not aware that the organisation was potentially a properly interested person and could 
attend the inquest to assist the coroner; we understand that Bolton Council had been contacted because 
the coroner's court understood that Bolton Cares is part of the Council and we believe that the Council 
considered  that  we had also been  contacted  separately.  Therefore there was a misunderstanding  for 
which we apologise.  

Had  Bolton  Cares  been  in  attendance  at  the  hearing,  we  would  have  provided  additional  information 
about  the  organisation,  our  policies  on  training  for  staff  members,  support  planning  and  associated 
guidelines and the findings from the internal investigation including the lessons learned and subsequent 
changes implemented.  

We deeply regret not becoming an interested party and providing all the relevant document to assist you 
with the inquest hearing. Our response below outlines how seriously we have taken this matter and how 
we have sought to address and alleviate the coroner's concerns. 

Regulation 28 Report  

Please find below our detailed response to each of the specific matters of concern you raise.  

A lack of understanding and/or training as to the specific requirements and expectations as to 
the role of care staff when supervising/ monitoring a service user. 

Our internal investigation found that all support staff were aware of the choking risk posed by Craig, the 
measures  in  place  to  reduce  this  risk;  including  how  his  food  was  prepared  and  how  he  was  then 
monitored and supervised whilst eating; and the care plans and SALT guidelines in place for him. The 
staff members who we spoke to were able to relay details from the guidelines during their interviews.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All support staff, apart from 
, stated that they would not leave Craig unsupported whilst he 
was eating. The guidelines read ‘supervise/monitor’ and the staff interviewed understood this to be that 
they should physically be with Craig whilst he was eating.  

We  consider  that  the  evidence  taken  at  the  inquest  supports  this; 
,  Support  Worker, 
stated "staff won't be too far away from him, observing him". In his statement he said that "there's normally 
two members of staff in close proximity". 

, Service Manager, confirmed in his evidence that he would "expect staff to be in eye shot of 

Craig". 

We believe this incident arose from one support worker, rather than staff [plural],  stating that he felt it 
adequate to ‘supervise/monitor’ Craig Spiby whilst he was eating, from another room. At the time of the 
incident Craig was eating his lunch at the dining table and the staff member supporting him was doing 
so  on  a  one-to-one  basis.  The  member  of  staff  left  him  to  put  away  some  items  in  another  tenant’s 
bedroom.  It  was  during  this  period  that  Craig  choked  on  his  sandwich.  This  is  not  something  Bolton 
Cares, or 

, the Service Manager, expected of 

. 

However, since the incident, we have provided refresher training to staff, by way of a toolbox 
talk,  to  confirm  what  is  expected  when  a  support  worker  is  required  to  be  supervising  or 
monitoring.  This  reinforces  to  staff,  that  they  must  remain  in  the  room  and  remain  physically 
present with the supported person, keeping them under observation whilst they are undertaking 
the task for which they require supervising or monitoring for.   

The  confusion  that  arises  in  the  existence  differing  language  that  applies  in  Care  Plans  and 
Guidance with no corresponding definition of the terms used. 

SALT (Speech and Language Therapy) guidelines and Eating and Drinking Guidance are provided by 
the Speech and Language Team from Bolton Community Learning Disability Team, Bolton Council. They 
do  use  the  terms  ‘supervise/monitor’  and these terms  are then reflected in our  own Provider  Support 
Plans. Following receipt of the Coroner’s report we have worked with Bolton Council and the relevant 
health colleagues and adult social care teams to address these issues. 

Bolton NHS Foundation Trust, who employ learning disability health professionals, including Speech and 
Language Therapists, have provided assurance to Bolton Council Adult Services and ourselves that they 
have  conducted  an  audit  of  various  eating  and  drinking  guidelines,  including  those  pertaining  to  Mr. 
Spiby.  

They found that whilst guidelines are comprehensive, the language used could lead to misinterpretation 
or lack clarity for staff and carers. To address this, a glossary of terms has been created and is being 
implemented across all health professional guidelines within the Community Learning Disability Team, 
not just those related to eating and drinking. This glossary aims to provide consistency and clarity across 
various guidelines. 

The  glossary  is  now  included  in  all  new  guidelines  produced  and  will  be  incorporated  into  existing 
guidelines  during  reviews,  or  when  changes  are  reported.  Clinical  staff  are  collaborating  with  Bolton 
Council to distribute the glossary to other commissioned services that support individuals with guidelines, 
ensuring broader awareness and minimising confusion.  

We have been informed that health staff will also be attending a Bolton Council organised provider forum, 
to  allow  for  continued  communication  and  co-production  regarding  the  review  of  the  formatting  and 
accessibility of guidelines. This will include providers, including ourselves and those people who access 
services and their representatives.  

If there are individual changes relating to any guidelines in place, or it is also felt within our services that 
there is a lack of clarity, we will be making the appropriate referrals into the Community Learning Disability 
Team for review.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Once these amended guidelines are in place, we will ensure that the terms of use are reflected in our 
support plans.   

Whilst we wait for this to be undertaken by SALT professionals within the Council, we are revising our 
support plans (where these terms are used both within SALT guidelines and individual support plans) to 
include a definition of supervision and monitoring. This is also included in the toolbox talk to staff as set 
out above and we are proactively including this on all team meeting agendas.  

How and why staff have assumed the deceased to have fallen asleep at a mealtime after a period 
of absence from the room, did not use more professional curiosity to evaluate whether such an 
assumption was correct or safe. 

As indicated at the outset of this response, the conduct of the staff member supporting Craig on the day 
of the incident was not that expected of our support workers. Bolton Cares did not foresee that a staff 
member would behave in such a manner and would have expected him to check that Craig was okay. It 
would not have been appropriate for Craig to have been left at the table had he fallen asleep.  

The other staff members who gave evidence at the inquest did not say that they would leave a service 
user to sleep and our internal investigation has not found that any other staff member would behave in 
this manner. 

Given the incident, we have reflected on this and incorporated instructions to staff via the toolbox talk 
and their  training  on  supervision  and monitoring to include carrying  out  checks  on  unusual  behaviour 
displayed by support users and a reminder that if support users do fall asleep, that they are checked and 
supported. 

The  lack  of  confidence  expressed  by  staff  in  the  emergency  first  aid  training  provided  when 
responding in a choking case.  

During our internal investigation into this matter, Bolton Cares considered the training provided to our 
workforce. All staff supporting Craig at the time of the incident had completed their mandatory First Aid 
training. In Bolton Cares Supported Living, we provide one day, face-to-face First Aid training which is 
accompanied by a face-to-face refresher training course every three years. The level of training provided 
is above the standards required. Online Training is considered an acceptable option, but we believe that 
face-to-face training is more effective and therefore provide this.  

During the training provided there is a course module solely dedicated to choking and how to respond. 
This training is refreshed face to face every three years.  

Since the incident we have provided every service that supports individuals with SALT guidelines with 
anti-choking devices and provided training on their use to put additional safeguards in place.  

Prior to the incident, Dysphasia/Safe Swallowing training was not a mandatory requirement for support 
workers  from  Skills  for  Care.  We  have  subsequently  reviewed  this  and  revised  our  policy.  All  staff 
supporting individuals with SALT guidelines now attend face-to-face Dysphasia training at Bolton Cares. 
This is currently being provided by our in-house trainer and SALT professionals from Salford Council.  
Due to the large number of staff who require this training in Bolton, our learning and development partner 
has approached Andrew Forbes (Speech & Language Therapist, Bolton) with a view to him providing 
additional training sessions in 2025. 

An absence of training to guard against confirmation bias with long term service users who have 
enduring high risk of choking, but no actual previously recorded episodes of such events. 

Craig was diagnosed with Phelan McDermid Syndrome. This syndrome increases the risk of choking and 
aspiration.  There  had  been  no  reported  episodes  of  choking  for  many  years,  but  the  risk  remained 
consistent. To address this, we have included a reminder of not becoming complacent within the toolbox 
talk  described  above  and  in  addition  to  the  SALT  guidelines,  which  we  currently  complete,  we  have 
implemented an electronic ‘Read and Sign’ record. This will ensure that new staff members are required 
to familiarise themselves immediately.  

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We  have  also  included  ‘SALT  guidelines’  on  our  managers’  bi-monthly  audits.  This  ensures  that 
Managers are physically checking guidelines and the electronic Read and Sign sheets at every audit to 
gain assurance that staff members are reading them and there is a constant refresher for all staff 

We have also included ‘SALT guidelines’ on our standard Team Meeting agendas. These team meetings 
take place every two months and by including this on the agenda we are reminding staff teams that the 
guidelines are in place and despite there being no incidents, the risk remains the same.  

Once again, we would like to take this opportunity to thank you for highlighting the matters of concern 
and  for  giving  us  the  opportunity  to  respond.  We  will  continue  to  work  with  our  colleagues  in  Bolton 
Council to ensure systems and practices continue to improve. 

Yours sincerely, 

Managing Director 

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