Source · Prevention of Future Deaths

Margaret Taylor

Ref: 2025-0420 Date: 12 Aug 2025 Coroner: Rebecca Ollivere Area: Gloucestershire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the absence of documented rationale or further SALT assessment before a patient was removed from a soft food diet. Additionally, food brought in by the patient's husband was not checked for suitability by care home staff.

Date 12 Aug 2025

56-day deadline 7 Oct 2025 stated in the report

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The coroner noted the absence of documented rationale or further SALT assessment before a patient was removed from a soft food diet. Additionally, food brought in by the patient's husband was not checked for suitability by care home staff.

View full coroner's concerns

There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet
- Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths.

Responses

1 respondent

Oak Tree Mews Care Home

Other

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AI-classified response stance Action Taken

AI-generated response summary

• The care home stated it now conducts full pre-assessments for nutritional needs, including swallowing difficulties, and updates care plans with relevant information. • It has informed family members and visitors, via letters and a digital signing system, to declare any food brought onto the premises. • The home has introduced protected lunch times, adjusted the dining area layout for resident visibility, and amended staff breaks to ensure staff presence during meal service.

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Dear , We are responding to the report received regarding the incident at Oak Tree Mews. We have taken this incident very seriously and have implemented several changes in the home. The manager at the time of the incident is no longer working at Oak Tree Mews due to personal reasons. The new manager has worked in care since 2003. She is fully aware of the incident and has worked alongside myself to implement the changes.  carries out a full pre assessment which ensures all nutritional needs can be met, including allergies, swallowing diƯiculties etc.  Care plans are created to ensure any SALT information etc. is included and they are updated as and when needed.  When completing care plans all risks are identiﬁed and appropriate agencies would be involved and their advice followed.  Care plans are updated regularly according to the needs of the residents, this will then be discussed with all staƯ.  A senior lead has been appointed to work alongside and staƯ to help with management and communication, as well as assisting the manager with paperwork etc.  We have introduced protected lunch times where we encourage family members not to visit relatives at this time. The manager and myself when at the home are also present in the dining room during lunch service and regular meal time experiences are completed.  The layout of our dining area has been changed as a result of completing a meal time experience to ensure that all residents are clearly visible whilst eating and that there is enough access room for residents and the staƯ.  StaƯ lunch breaks have been amended to ensure that all staƯ are present during lunch service.  Family members were given a letter to explain about our protected lunch times and that we would like them to declare any food being brought onto the premises.  We have a digital signing in system now for all visitors to the Home and on the screen we have a notice which they have acknowledge, reminding them to make staƯ aware of any food they are bringing onto the premises.  We also encourage all our residents to have meals in the dining room to make them visible.  All staƯ complete First Aid training on our online system. StaƯ have also had intensive in house ﬁrst aid training, which was a course that lasts 3 years.  Dependency levels are checked and updated to continue to ensure correct staƯing levels. We ensure that the quality of care provided is in the best interest of our residents.

Report sections

Investigation and inquest

On 25th November 2024, an investigation was commenced into the death of Margaret Taylor. The investigation concluded at the end of the inquest on 12th August 2025. The conclusion of the inquest was as set out below.

Circumstances of the death

Margaret (Maggie) Taylor was 80 years old and resided at Oak Tree Mews Care Home in Gloucestershire. She suffered with Dementia, and Dysphagia, and a Speech and Language Therapy (SALT) review, had identified her as a severe risk of choking. She was last assessed on 9th September 2024, and placed on a level 5 soft food diet and thickened fluids. Food was to be soft and mashed. No review of her SALT assessment was carried out in October 2024, however, she was taken off the level 5 diet and this communicated via a Whatsapp message to all staff at the care home. There does not appear to be any rationale for this decision, and it does not seem to be a decision taken following a proper assessment. On 8th November 2024, Maggie’s husband took into the care home, a chicken wrap, which he fed to Maggie. The evidence I heard was that he believed that Maggie had been removed from the soft food diet. He also indicated that the food was not checked for suitability by the staff at the home. I heard that this is against the policy of the home, which indicates that all food should be checked by staff. Sadly, Maggie began choking on a piece of chicken, and despite the best efforts of all involved, and paramedics who attended, she could not be resuscitated, and died at 12.40pm on 8th November 2024. The conclusion of the Inquest was that Margaret died as the result of an Accident. It is not known whether had the staff checked the food brought in by Mr Taylor, it would have been highlighted as not suitable, as she had been taken off the soft food diet, and so it may well be that it would still have been allowed. Therefore, I cannot say that there would have been any difference to the outcome for Maggie in this case had the staff checked the food.

Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk

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Shared signals

Report details

Reference: 2025-0420
Date of report: 12 August 2025
Coroner: Rebecca Ollivere
Coroner area: Gloucestershire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Oct 2025 (stated in the report).

Sent to

Oak Tree Mews Care Home

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Data: judiciary.uk.

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