A jury has concluded that a 41-year-old man died from choking having been fed an “inappropriate and unsuitable” meal at his care home in Essex.
Paul Spearing – who required 24-hour, 1-to-1 care – died on 15 November 2023 having been fed a croissant in milk. Speech and Language Therapy (SALT) advice in 2018 and 2019 had made clear that Paul – who suffered from dysphagia – should not be given mixed consistency foods or thin fluids, such as unthickened water or milk.
Jim Duffy represented Paul’s family, instructed by Sarah Westoby of Leigh Day. The inquest took place over eight days at Essex Coroner’s Court. The family was supported by the charity, INQUEST.
Paul had cerebral palsy as a result of a birth injury. He had lived at the Essex Care Consortium home in Colchester for some 20 years. Paul was entirely dependent on staff for his care needs, including all preparation and consumption of food and drink. He was at risk of choking due to his ataxia and dysphagia. In 2019, abdominal thrusts were administered after Paul began choking on an apple.
The jury found that the meal Paul had been given constituted a failure to adhere to Paul’s SALT requirements, and that this caused his death. They also identified the following possibly causative factors:
- The content of the care home’s guidance on Paul’s mealtime preparation, food and fluid needs (including care plans, risk assessment and guidance within menus). This was inadequate, inconsistent and lacked clarity.
- Staff had an insufficient working knowledge of Paul’s mealtime SALT requirements, despite a recommendation by SALT that staff receive dysphagia training. This had been “stressed as being essential” in order to avoid the risk of aspiration or asphyxiation. There had been no specific or good reason why the recommendation had not been followed. The jury heard that the training cost £14 per participant, and that the care home had been receiving funding of £3,672 per week for Paul.
- A procedure for staff caring for 1:1 patients to share a buzzer between them “was inadequate and not communicated to staff or monitored.”
The jury reached a narrative conclusion that included a finding of misadventure.
The incident took place in a private care home, where Paul was under Deprivation of Liberty Safeguards (DoLS). His care had been funded via NHS Continuing Healthcare. The Coroner accepted Jim’s argument that the state’s investigative duty under Article 2 of the European Convention on Human Rights was engaged.
News coverage:
