Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance.

The Coroner identified failures by Surrey County Council including:

a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services.
b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently.
c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently.
d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family
e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan.
f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family.
g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family.
h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks
i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken.

There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.