Source · Prevention of Future Deaths
Norman Barnes
Ref: 2022-0045
Date: 14 Feb 2022
Coroner: Bina Patel
Area: Mid Kent & Medway
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryCare home staff were unaware of specific dietary recommendations in the care plan for a resident with Parkinson's disease. They generally did not access or utilise key information contained in care plans and risk assessments.
Date
14 Feb 2022
56-day deadline
11 Apr 2022 est.
estimated from the report date
Responses identified
0 of 2
Coroner's concerns
Care home staff were unaware of specific dietary recommendations in the care plan for a resident with Parkinson's disease. They generally did not access or utilise key information contained in care plans and risk assessments.
View full coroner's concerns
Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that:
(1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident.
(2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents.
(1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident.
(2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents.
Report sections
Investigation and inquest
On 22nd November 2021 I commenced an investigation into the death of Norman Barnes who died, aged 67, on 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent. The investigation concluded at the end of an inquest on 10th February 2022, conducted by me. I gave a narrative conclusion that: Norman Barnes died on the 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent. He had choked on food whilst eating his lunch in the lounge of the care home. His lunch was not minced or moist as per the recommendation of his SALT assessment and devised care plan. This occurred on a background of Parkinson’s disease which affected his swallow.
The medical cause of death was:
Ia. Inhalation of Food Ib. 1c
II. Parkinson’s Disease
The medical cause of death was:
Ia. Inhalation of Food Ib. 1c
II. Parkinson’s Disease
Circumstances of the death
Norman Barnes died on the 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent. He had choked on food whilst eating his lunch in the lounge of the care home. His lunch was not minced or moist as per the recommendation of his SALT assessment and devised care plan. This occurred on a background of Parkinson’s disease which affected his swallow.
Copies sent to
Care Quality Commission9. SignatureBina Patel, Area Coroner, Mid Kent & Medway 14th February 2022
Similar PFD reports
Report details
- Reference
- 2022-0045
- Date of report
- 14 February 2022
- Coroner
- Bina Patel
- Coroner area
- Mid Kent & Medway
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Apr 2022 (estimated from the report date).
Sent to
- Ashley Gardens Care Centre
- Care Quality Commission