Kenneth Clarke

On the 3rd August 2017 , commenced an investigation into the death of Mr Kenneth Clarke: The investigation concluded at the end of the inquest on 25 February 2020 conclusion of the inquest was misadventure contributed to by neglect of the Nursing Home Mr Kenneth Clarke was resident in The cause of death was; 1a Inhalation of food material,

Mr Clarke was a 74 year old gentleman who was resident in Normanton Village Nursing home His past medical history included strokes, which had left him with issue swallowing, and thus a high risk of chocking_ He also suffered with dementia He was on a puree only food diet but his dementia meant he did not appreciate this would often wonder round the home in search of food. Mr Clarke had been risk assessed by the home and to reduce his risk of choking, measures were put in place Firstly, he was on a puree food diet. Secondly, he had a he had & pressure sensor mat to the side of his bed to alert staff when he left his room; Thirdly, staff were to be stationed at observation points around to observe if patients left their rooms_ Fourthly, the kitchen, where food could be accessed, was to be locked and had a pin operated lock was in place Finally, food was to be kept in cupboards in the kitchen or in the fridge [ILI: PROTECT] Village and The View and

On the 23ra July 2017 Mr Clarke left his room: The pressure sensor mat did not activate. It is not clear whether this was because it was not working: Whether it was in the correct place, or whether Mr Clarke moved it himself: The staff at the home were not at the designated observation points and did not see leave his room He made his way to the kitchen, which was unlocked. He ate a piece of bread that had been left out and not put away in a cupboard or fridge. He choked and died,

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_ You may wish to consider a review of the policies governing Normanton Village View Nursing Home and other Homes within the group_