Source · Prevention of Future Deaths

John Lee

Ref: 2023-0505 Date: 6 Dec 2023 Coroner: Anna Crawford Area: Surrey Responses identified: 1 / 1 View PDF

Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

Date 6 Dec 2023

56-day deadline 31 Jan 2024 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

View full coroner's concerns

The MATTER OF CONCERN is: The Court is concerned that there is a risk that dementia patients at the Trust are not receiving mouth care on each occasion that they eat and this presents a risk of future deaths.

Responses

1 respondent

Surrey and Sussex Healthcare NHS Trust NHS / Health Body

9 Feb 2024 PDF

Action Taken

The Trust has already undertaken several actions, including updating the dysphagia e-learning module, introducing a rolling training programme, and planning a swallow awareness event in March 2024. It will also review the Meal time policy, relaunch Red Tray guidance, and produce communication materials promoting dysphagia awareness. (AI summary)

View full response

Dear Ms Crawford Regulation 28 Report- response by Surrey & Sussex Healthcare NHS Trust Inquest touching upon the death of John William Lee (Date of Birth 07/03/193~) This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 29 September 2023, made subsequent to the inquest into the death of Mr Nickols, which was concluded on 20 November 2023. The Trust was given until 31 January 2024 to respond to the coroner, pursuant to . Regulation 29(5) Coroners (Investigations) Regulations 2013. I am very sorry for the delay in providing this response to you, it has been an exceptionally busy period in the Trust and our focus has been directed to our patients and their safe care. We would like to start this response by offering our sincere condolences to Mr Lee's family for their loss. The Trust accepts fully the findings of HM .Coroner, and that there . was failure to follow the SALT recommendations to closely monitor Mr Lee whilst he was eating and drinking, and to check his mouth after eating for items of food or debris. We are truly sorry that Mr Lee died as a result of choking on food that he had retained in his mouth, and we accept that had the SALT recommendations been followed, then Mr Lee would not have died when he did. The Prevention of Future Deaths report identifies the following area of concern, and we address this in the response, with details of the actions that we have undertaken

and those that we plan to undertake, along with the details of the improvement to date that have already resulted from these actions in the appended Action Plan . The Court is therefore concerned that there is a risk that dementia patients are not receiving mouth care on each occasion that they eat and that this presents a risk of future deaths. I asked , Consultant Admiral Nurse for Dementia to review the care dementia patients receive specifically in relation to mouth care when eating and to include their dietary and swallow assessments from the time of their admission. The review included expertise from , Mouthcare Lead;

Clinical Lead for Speech and Language Therapy [SALT}; and , Chief Nurse Informatics Officer. As a result of the review, the Trust identified eight actions to enhance the patient's care pathway, and ensure risks are identified and measures put in place ·to help prevent and safeguard a dementia patients' risk when eating. We intend to keep the focus on improving dementia patients care and the actions detailed below will achieve this. . To ensure patients, receive harm free and high quality nutritional care, it is vital that those patients at risk are identified and placed on the correct care plan in a timely manner. This will be achieved through the effective use of screening tools and enhancing staff knowledge. The Trust will create a Food Strategy Nutrition Steering Group which will advise the Trust on all aspects of nutrition from food provision through to intravenous nutrition support. This group will monitor numbers and trends in incidents and ensure action plans are followed through; it will seek assurance of the nutrition and hydration elements of harm free care within the Trust and provide assurance to the Board via the Quality Committee by the Chair of Nutrition Steering Group. This will ensure that the Trust's systems in relation to both food and investigations are safe. A strategy document will also be created in the coming year which sets out how the Trust will ensure that it provides safe, high quality nutritional care for all, over the next 3 years.

Report sections

Investigation and inquest

An inquest into Mr Lee’s death was opened on 8 December 2022. The inquest was resumed and concluded on 20 November 2023.

The medical cause of Mr Lee’s death was:

1a. Choking

2. Dementia

With respect to where, when and how Mr Lee came by his death it was recorded at Box 3 of the Record of Inquest as follows:

Mr Lee was an 83 year old man with dementia who lived in a care home. On 17 August 2022 Mr Lee was admitted to East Surrey Hospital following a fall. By 31 August 2022 Mr Lee was medically fit for discharge, however, he remained in hospital while efforts were made to find him a more suitable care home. Whilst he was in hospital Mr Lee was found to have a newly impaired swallow, the primary cause of which was thought to be his worsening dementia, which placed him at risk of choking and aspiration. On 1 September 2022 Mr Lee was assessed by the Speech and Language Team (SALT Team) as being suitable for normal consistency foods, however, a number of recommendations were put in place to minimise the risk of choking and aspiration. These included to monitor him closely whilst he was eating and to check his mouth after eating to locate and remove any food debris. This recommendation was made because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. On 2 September 2022 hospital staff did not complete Mr Lee’s food chart from mid-morning onwards and, as such, it has not been possible to establish what and when Mr Lee ate on 2 September 2022, save for the fact that he ate breakfast. However, Mr Lee had food residue in his stomach at post-mortem, which is consistent with him having a eaten a further meal or meals after breakfast. Overnight on 2-3 September 2022 Mr Lee was confused and agitated and repeatedly tried to get out bed. He remained agitated until approximately 3am when he settled down and went to sleep. At approximately 5.30am he was found unresponsive and his death was formally declared by a doctor later that morning on 3 September 2022. A post-mortem examination was conducted which found that Mr Lee had died due to choking on a piece of food. It has not been possible to establish precisely when on 2 September 2022 Mr Lee ate the food that he subsequently choked on. However, having eaten it, he retained it in his mouth for a period of time before subsequently choking on it. Had Mr Lee been closely monitored and provided with effective mouthcare on each occasion that he ate on 2 September 2022, in accordance with the SALT recommendations which were in place for him, he would not have choked and he would not have died

The inquest concluded with a short form conclusion of ‘Accidental Death’ together with the following short narrative conclusion:

Mr Lee was not closely monitored or provided with effective mouth care whilst eating on 2 September 2022. Had he been closely monitored, and provided with effective mouth care thereafter, he would not have choked and died on 3 September 2022.

Circumstances of the death

During the course of the inquest the court heard evidence from of the hospital’s SALT team that it was standard practice for dementia patients to have their mouths checked after eating, in order to locate and remove any food debris. This is because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking.

However, Mr Lee’s mouth care records indicate that he had only received mouth care once daily during the entirety of his hospital stay.

The Court is therefore concerned that there is a risk that dementia patients are not receiving mouth care on each occasion that they eat and that this presents a risk of future deaths.

Copies sent to

10 SignedANNA CRAWFORDAnna Crawford H.M Assistant Coroner for Surrey Dated this 6th day of December 2023

Inquest conclusion

Mr Lee was an 83 year old man with dementia who lived in a care home. On 17 August 2022 Mr Lee was admitted to East Surrey Hospital following a fall. By 31 August 2022 Mr Lee was medically fit for discharge, however, he remained in hospital while efforts were made to find him a more suitable care home. Whilst he was in hospital Mr Lee was found to have a newly impaired swallow, the primary cause of which was thought to be his worsening dementia, which placed him at risk of choking and aspiration. On 1 September 2022 Mr Lee was assessed by the Speech and Language Team (SALT Team) as being suitable for normal consistency foods, however, a number of recommendations were put in place to minimise the risk of choking and aspiration. These included to monitor him closely whilst he was eating and to check his mouth after eating to locate and remove any food debris. This recommendation was made because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. On 2 September 2022 hospital staff did not complete Mr Lee’s food chart from mid-morning onwards and, as such, it has not been possible to establish what and when Mr Lee ate on 2 September 2022, save for the fact that he ate breakfast. However, Mr Lee had food residue in his stomach at post-mortem, which is consistent with him having a eaten a further meal or meals after breakfast. Overnight on 2-3 September 2022 Mr Lee was confused and agitated and repeatedly tried to get out bed. He remained agitated until approximately 3am when he settled down and went to sleep. At approximately 5.30am he was found unresponsive and his death was formally declared by a doctor later that morning on 3 September 2022. A post-mortem examination was conducted which found that Mr Lee had died due to choking on a piece of food. It has not been possible to establish precisely when on 2 September 2022 Mr Lee ate the food that he subsequently choked on. However, having eaten it, he retained it in his mouth for a period of time before subsequently choking on it. Had Mr Lee been closely monitored and provided with effective mouthcare on each occasion that he ate on 2 September 2022, in accordance with the SALT recommendations which were in place for him, he would not have choked and he would not have died

The inquest concluded with a short form conclusion of ‘Accidental Death’ together with the following short narrative conclusion:

Mr Lee was not closely monitored or provided with effective mouth care whilst eating on 2 September 2022. Had he been closely monitored, and provided with effective mouth care thereafter, he would not have choked and died on 3 September 2022.

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Report details

Reference: 2023-0505
Date of report: 6 December 2023
Coroner: Anna Crawford
Coroner area: Surrey

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: 31 Jan 2024 (estimated).

Sent to

Surrey and Sussex Healthcare NHS Trust

Part of a series

2 reports

2018-0349 0 responses identified

Source links

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Data: judiciary.uk under OGL.