TozerInquest

Danny loved nature, people and cups of tea. He died unexpectedly on September 22 2015, aged 36. His inquest starts 17 April 2018. Tweets by @GeorgeJulian

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Family statement at the conclusion of the inquest into Danny Tozer https://t.co/irr7mTXzMe

cc @mencap_charity @CityofYork @ValeofYorkCCG

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Coroner thanks Mr and Mrs Tozer for their dignity... it was clear how much Danny was loved. Coroner offers his sincere condolences

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Cause of death:
Hypoxic ischemic brain damage
Cardio respiratory arrest
SUDEP

Died 17:50 hours on 22 September 2015

No evidence of neglect, Daniel Tozer died of natural causes

All that remains therefore for me is to thank the representatives in this matter

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I find the communication between @mencap_charity @CityofYork and Danny's family was not satisfactory

I do not find neglect in this inquest. I acknowledge that a DOLS had not been applied for but I find this did not contribute to the death in this inquest

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Coroner finds:

Danny Tozer moved from Liverpool to York over a 9 mth transitional period between 2012 and 2013, core assessment was already in place.... was an epilepsy risk assessment reviewed following feedback from the family

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PBS plan was not followed in terms of 10min checks on 21 Sept, that failure did not cause or contribute to Danny's death

SUDEP only control mechanism would be constant monitoring and even then would not be sufficient if involved interictal or non convulsive seizure

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One further piece of evidence relating to 'they' in the Police, that inquiry proved negative, no other evidence of police involvement

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In addition evidence read regarding staffing levels, number of staff and residents @mencap_charity Maple Avenue on 21 September

Other email was to company who supplied the sensor mat

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Coroner summarises Ralph Edwards, Principal Social Worker @CityofYork evidence

His main evidence related to actions taken after Danny's death

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Coroner summarises Gill Poole's evidence

She was commissioned by @CityofYork to undertake an independent review

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Coroner summarises Dr Foster, Consultant Neurologist's evidence