Emma Turner last had a welfare check in 2019. Derby City Council say they are carefully considering a report into her death
Sophie Fagone Buscimese Trainee Reporter
13:35, 06 Mar 2026
Emma died at her home in Sinfin
A woman’s death has raised concerns about social services in Derby, with a coroner saying future deaths could occur unless action is taken.
Emma Irene Turner died on January 29, 2023, at her home in Sinfin after her airway became obstructed because she had eaten cake.
Sabyta Kaushal, Assistant Coroner for the coroner area of Derby and Derbyshire, said the 30-year-old was “profoundly disabled” with quadriplegic athetoid cerebral palsy since birth.
The inquest found that adequate checks on Emma’s well-being had not been carried out, and her safeguarding adult referrals were never fully addressed.
It also found that speech and language therapists did not see Emma in person for 11 years between her transition from child to adult services.
After she was assessed by the speech and language therapists, they advised that she should only eat pureed food.
No face-to-face assessment regarding her clinical needs, her social needs, nor adequate welfare checks were undertaken from 2019 until her death in 2023.
“It is clear that her family cared and supported her, but at the inquest, the evidence exposed important issues with information sharing between services,” Kaushal said.
“Her mother, her carer, should have been given more support and assisted in understanding what was in Emma’s best interests.”
She explained that the evidence at the inquest revealed that the different agencies responsible for Emma’s care had no system for exchanging information, meaning they could not review how other professionals would intervene in her care.
The inquest also found there had been a history of non-attendance at appointments and a reluctance among family members to engage with services.
As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Miss Kaushal said that whilst evidence from the GP surgery, Derby City Council, and their safeguarding team confirmed that a number of changes to support patients with learning difficulties had been made, more action would be needed.
According to the coroner, the current safeguarding referral form, which needs to be completed by a GP for vulnerable and learning difficulties adults, is not tailored to the concerns a GP would raise.
“The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies, e.g. care homes, the police and community mental health teams,” Kaushal added.
“As a result, there is a risk of there being a lack of key information provided to the safeguarding teams.
“Thus, the safeguarding team may be delayed in responding in a timely way.
“In my opinion, action should be taken to prevent future deaths.”
A spokesperson for Derby City Council said that since Emma’s death, work had been undertaken to strengthen safeguarding processes.
“Our condolences remain with Emma Turner’s family. Derby City Council takes the findings of the Prevention of Future Deaths report seriously,” they said.
“Since Emma’s death, work has already been undertaken with partners to review the circumstances and strengthen information sharing and safeguarding processes for vulnerable adults, including those with learning disabilities.
“We are carefully considering the coroner’s report and will provide a full response within the required timeframe, setting out any further actions to ensure the learning is fully embedded.”
