An inquest was held into the death of a care home resident, resulting in the coroner ruling ‘measures should be taken’ after reports indicated the death could have been prevented.
Nadia Persaud, who is the coroner for East London area has reinforced the need for preventative measures in a care home after an inquest on July 10 deemed the circumstances surrounding the death of Richard Fitzgerald, who suffered from Alzheimer’s, ‘concerning’.
Mr Fitzgerald was admitted to a care home in October 2022. In March 2023 he suffered a choking episode and required admission to hospital following the incident. After being discharged from primary medical care, Mr Fitzgerald underwent speech and language therapy (SALT) assessment. The assessment confirmed that Mr Fitzgerald was at risk of choking due to eating too fast. A care plan was devised by the SALT team to minimise his risk. His nutritional plan was also updated.
On June 24 of last year Fitzgerald had breakfast in his bedroom whilst supervised by a senior carer, after he finished his breakfast the carer was attending to another patient when she heard a ‘wheezing sound’. The carer found Mr Fitzgerald had difficulty swallowing and it was assessed that the patient somehow accessed ‘uncut food from the breakfast trolley’. Measures were taken to clear the food blockage and the emergency alarm was pressed. A nurse also attempted to clear Mr Fitzgerald’s airway. Shortly before the first paramedic’s arrival the patient had stopped breathing and was found to be in cardiac arrest. The care home staff were observed not to be providing emergency resuscitative measures when paramedics arrived on the scene.
Emergency measures to commence basic life support were expected. The coroner concluded that this would have ‘saved Mr Fitzgerald’s life’.
Mr Fitzgerald died in King George Hospital after a brain injury on June 26.
Ms Persaud concluded the inquest with the following concerns: ‘During the course of the inquest the evidence revealed matters giving rise to concern. ln my opinion there is a risk that future deaths could occur unless action is taken. ln the circumstances it is my statutory duty to report to you. The Care Home staff were aware that the SALT care plan could not be consistently followed in terms of close supervision, but did not discuss this with the SALT team to ensure that a contingency care plan could be put into place. The risk of Mr Fitzgerald picking up unsafe food was known to staff, but was not incorporated into the choking risk assessment and risk management plan. The emergency protocol for choking was not followed by the staff in attendance on 24 June 2023 (including qualified nursing staff).
The Care Home’s investigation lacked thoroughness and professional curiosity and action should be taken.’
