Source · Prevention of Future Deaths

Norman Barnes

Ref: 2022-0045 Date: 14 Feb 2022 Coroner: Bina Patel Area: Mid Kent & Medway Responses identified: 0 / 2 View PDF

Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.

Date 14 Feb 2022

56-day deadline 11 Apr 2022 est.

Responses identified 0 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.

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.

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

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

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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).

Sent to

Ashley Gardens Care Centre

Care Quality Commission

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.