What happened
Ben King, 32, had Down’s syndrome, a severe learning disability, ADHD and communication difficulties. He lived with his mother in Norfolk until she fell ill, then moved to Cawston Park Hospital on 8 July 2018, where he was detained under the Mental Health Act continuously until his death two years later.
He had obstructive sleep apnoea and struggled with the firm facial mask. Promethazine was prescribed at first to help him tolerate the mask, then used to control agitated behaviour. Care staff told the inquest they did not know its risks in someone with respiratory problems.
In the early hours of 28 July 2020 staff recorded oxygen saturations of 35 per cent. Below 70 per cent is life-threatening. The readings continued for 24 hours and he was drowsy and unwell. The consultant was called and advised against oxygen or calling 999. His mother visited, saw his condition and asked for an ambulance. He begged to go home.
That evening he was agitated and given promethazine. At 1.15am his saturations were recorded for the last time, at 35 per cent. Nobody took observations until 5.05am. At 7.07am a nurse could not rouse him and called 999. He died that evening at Norfolk and Norwich University Hospital.
The outcome
An inquest before HM Senior Coroner Jacqueline Lake ran at Norfolk Coroner’s Court from 28 June to 9 July 2021. The jury concluded that Ben “died due to inadequate weight management and failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine”, and found a failure to identify the seriousness of a life-threatening situation.
BBC News reported that the hospital had been in special measures since 2019, closed on 12 May 2021, and that Norfolk Police were investigating his treatment. No charge is recorded in the sources read here.
What went wrong
Three A&E attendances for low oxygen in the weeks before he died led to no admission. Weight was never a clinical goal, though he gained more than two stones and the risk of obesity hypoventilation syndrome was known.
On the final night a saturation of 35 per cent was recorded at 1.15am and not checked again for nearly four hours. The consultant had advised against oxygen and against a 999 call.
What it teaches
Chemical restraint is restraint. Nobody had their hands on Ben King. A drug given to manage behaviour in a man with a breathing disorder carried the risk of a physical hold with none of the visibility: no observer, no one whose task was to end it.
The monitoring failure is the one that kills in prone restraint too. A number that is life-threatening at eight in the evening is still life-threatening at one, and the plan has to name who is watching it. Sedation hides that: a drowsy man with low oxygen looks settled.
Questions for the room
- 35 per cent at 1.15am, nothing until 5.05am. What does your service require at that reading, and whose name is against it?
- A consultant advised against oxygen and against 999. What would let a junior member of staff go past that advice?
- Staff said they did not know the risks of promethazine in sleep apnoea. Whose job was it to know?
Evidence and limits
Confidence: confirmed. The inquest evidence and the jury’s conclusion are carried from the INQUEST press release of 13 July 2021; BBC News corroborates the weight gain and the closure. Proceedings concluded on 9 July 2021, so the page may be cited outward.
One reported detail is not used: that he was struck twice by a member of staff at 6am. It is not in the vault record or the conclusion as summarised, so this page does not assert it.
Our physical interventions training covers restraint risk, including the kind where nobody is holding the patient.
Sources
Reviewed 20 October 2026.