Oxfordshire CCG report outlined another catalogue of concerns around the care of Nico Reed found dead in 2012 at a supported living facility having choked on his vomit. His parents feel his death could have been prevented but the report echoed the inquest in saying they couldn’t be sure of this despite the failures outlined. However, it does identify yet again the failures also in communication with the family. This was once again Southern Health NHS foundation Trust again – where similar findings were seen in the death of Connor Sparrowhawk who died in their care in the bath in 2014. In the face of the NHS review of 103 deaths of patients with learning disabilities in 2016-17 finding of 13 dying as a direct result of failures to provide adequate, safe and prompt care, it’s difficult not to see this as yet another given the lack of checks which should have been done, staff unable to do basic life support procedures, no suction equipment and the delay in calling for an ambulance… It also leaves one wondering whether had the issues been identified at the time Connor’s support might have averted his death..