A catalogue of failures by Surrey County Council and an education trust contributed to the death of a diabetic teenager over Christmas, an inquest has found.

Jake Baker, who had learning disabilities, died on December 31, 2019 while visiting his family home in Woking from a residential special needs college in Gloucestershire.

Jake arrived home on Christmas Eve, became unwell on December 28 and was found unresponsive in the early hours three days later. 

Coroner Carolyn Topping said Jake’s death from diabetic ketoacidosis was avoidable and if he had been admitted to hospital any time before 5pm on December 29 he would have been successfully treated.  Ms Topping issued a list of failures by Surrey County Council and Ruskin Mill Trust that contributed to Jake’s death. 

The coroner said there was a systemic failing by the council to adequately train and oversee personal advisers about their legal obligations in preparing pathway plans for children leaving care. 

She said Ruskin Mill Trust failed to ensure Jake’s safety when he went home for contact with his family. 

The 18-year-old had been at Ruskin Mill College in Stroud for 15 months after living at Burbank children’s home in Woking where he was diagnosed as diabetic at 13 and coeliac at 14. 

The inquest was told that Burbank took responsibility for Jake’s care and his family saw him around four times a year for supervised visits. They were given regular updates about his care and progress from his key worker. 

However, when Jake moved to Ruskin Mill College the family were told this was his “road to independence”. 

Jake’s stepfather told the inquest that the family had little contact with college staff except when reviews were due. 

Following Jake’s death an investigation into the support provided by Ruskin Mill Trust found there had been a breach of Care Quality Commission regulations to safeguard adults.  

Transform Residential Limited, which is responsible for providing care services to the trust, was found to have been criminally liable and was fined.  

The coroner said Jake lacked the ability to be wholly independent in managing his diabetes. He was not given any information about the dangers for him to have unsupported contact if his blood sugars became imbalanced. He was not trained to manage his diabetes if he became unwell.

Jake’s family said: “Losing Jake has been incredibly difficult, especially as he died in our home at what should have been a happy time. We trusted Ruskin Mill Trust with Jake’s care, and we have been let down by them in the worst possible way. 

‘‘Before Jake turned 18, he had a key worker we trusted and who he had a great relationship with. We were able to spend time together as a family safely, knowing that Jake was well supported by the staff at Burbank children’s home. 

“This changed when Jake moved from Burbank to Ruskin Mill College.

“Jake was an enthusiastic and determined young man who always put his mind to things. He had a kind soul and would get very excited when meeting new people. He loved dogs and playing pranks on his brothers and sisters.