The inquest concerns P who died from choking on marshmallow sweets he took from another resident’s plate during an activity in his care home on 1 February 2024. Immediate good quality first aid was not able to remove the airway blockage before a hypoxic brain injury had been sustained and he died in Charing Cross Hospital on 8 February 2024 from the consequences of this incident.
It was well documented and recognised that P had a high risk of aspiration due to an impaired swallow, and impulsively sought inappropriate food items, as a consequence of multiple strokes he suffered in 2006 and 2019, which caused him to suffer frontal lobe damage to his brain. P was exposed to a known risk.
P originally had 1:1 24/7 care. In May 2023, 1:1 funding was then removed with no consulting of P’s family, who would have raised robust objections due to ongoing risks. The ICB could not evidence why the 1:1 care was removed immediately and completely, or why P’s family were not consulted, and the care home did not ask for a review. If asked, the carers would have raised concerns about the removal of the care as there was a foreseeable risk. The ICB have confirmed that the assessment form will be changed, in particular to ensure next of kin are consulted. The care home has also accepted the findings of the safeguarding review carried out by the local authority adult safeguarding team and considerable training has been given to staff members. There are now mandatory risk assessments for new residents carried out before they arrive at the home and mandatory activity assessments.
The Coroner concluded that the cause of death was accidental death contributed to by neglect, finding a clear, causal connection between the risk and the death.
Alice was instructed on behalf of P’s family by Denise Broomfield from Action Against Medical Accidents.
