A jury at Bradford Coroners’ Court has concluded that neglect contributed to the death of a 54 year-old woman who died after choking on an apple. Rita Britten, who suffered from schizophrenia, was being treated at Dewsbury & District Hospital’s Priestley Unit following a deterioration in her mental health that had coincided with the illness and death of her mother. Jim Duffy represented Rita’s son, Andrew Britten.
Rita had been an in-patient at the Lyndhurst Rehabilitation Unit in Halifax since 2015, but was detained under s.3 of the Mental Health Act and transferred to the acute setting of the Priestley Unit on 20 July 2018. It had been decided that Rita was too ill to attend her mother’s funeral, which took place the same day.
Staff at Lyndhurst had been aware that Rita presented a choking risk, and that this increased as her mental health deteriorated. They also knew that she had experienced eight separate choking episodes since 2014, most recently when she had choked on a sandwich some three weeks prior to her transfer.
Under questioning, a witness presenting a serious investigation report on behalf of South West Yorkshire Partnership NHS Foundation Trust accepted that none of that information was passed from the Lyndhurst Unit to the Priestley Unit, and that it ought to have been. A risk assessment that had was shared went no further than to state that Rita had experienced “choking episodes in the past.” In any event, that risk assessment – contained within voluminous electronic records – was not read by Rita’s treating consultant psychiatrist at Priestley, nor by the mental health support worker who ended up supervising Rita on the day in question. She told the court that she had been unaware that Rita posed any choking risk.
The choking incident
On 26 July 2018, Rita grabbed an apple from a bowl in the Unit’s communal kitchen and started quickly taking small bites of it. She then took one very large bite before starting to choke.
Her support worker and a colleague sought to assist her, but Rita clenched her teeth before turning blue and suffering a cardiac arrest. None of the ward staff attending the emergency sought out the defibrillator that was available in the next room.
Rita’s BMI placed her just inside the ‘obese’ category. Her treating consultant psychiatrist explained that, having concluded that a conventional ‘Heimlich’ manoeuvre would not be achievable, he attempted to dislodge the blockage by means of what he described as an ‘auto-Heimlich’. This was a technique he had employed successfully upon himself in 2002. He acknowledged that it had not been approved in the UK.
In Rita’s case, this involved the psychiatrist placing himself on a high-backed chair underneath Rita with her head and upper body inverted over the back while he held her legs. The psychiatrist revealed in oral evidence that he had ‘passed out’ during this unsuccessful attempt to use gravity to remove the apple.
After the crash team and paramedics arrived, Rita’s circulation returned, but she died from hypoxic brain damage three days later at Pinderfields General Hospital.
The jury returned a narrative conclusion, finding that Rita’s death had been contributed to by neglect. Risk assessments had not been updated and completed in June and July 2018 as they ought to have been, and the Lyndhurst Unit failed to pass on the information about Rita’s choking risks and history to staff at the Priestley Unit. The latter did not have knowledge of Rita’s behaviours and risks, all of which contributed to her tragic death. The jury cited a lack of communication, insufficient handover, system shortfalls in relation to risk assessments and inadequate first aid training.
Call for clear national guidance
HM Assistant Coroner John Broadbridge also accepted that he should issue a Prevention of Future Deaths Report to both NHS England and the Resuscitation Council, calling for clear emergency guidelines in relation to choking incidents involving people who are overweight or otherwise less amenable to first aid in the form of conventional abdominal thrusts.
The case was featured in the press here.