Source · Prevention of Future Deaths

Ashley Notson

Ref: 2018-0207 Date: 29 Jun 2018 Coroner: Peter Dean Area: Suffolk Responses identified: 0 / 2 View PDF

There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.

Date 29 Jun 2018
56-day deadline 9 Oct 2018 est.
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
View full coroner's concerns
The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training: Fortunately, the carer on duty at the time of the incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present: The inquest also heard that; at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person are looking after; but that this was not a legal requirement either:

Report sections

Investigation and inquest
At the conclusion of the inquest into the very sad death of ASHLEY ERNEST NOTSON recorded a conclusion of 'Accidental death'. The cause of death was found t0 be: 1a Hypoxic brain injury to 1b Hypoxic cardiac arrest due to 1c Upper airway obstruction from inhalation of a foreign body, with Autistic spectrum disorder in Part II.
Circumstances of the death
Ashley Notson died in very tragic circumstances at the age of 55 after a period of time in hospital where he was taken after choking on a piece of meat at the care home in which he lived. Attempts to resuscitate him, including Heimlich manoeuvres, were conducted by a staff member on at the care home who had previously had training in first aid but; Mr Notson passed away from hypoxic brain injury resulting from the choking episode.
Action should be taken
Although appropriate assistance was given promptly here, despite the tragic outcome, it is clearly foreseeable that additional problems could occur in another care home if carers did not have first aid training or carry a mobile or portable telephone: To try to reduce the risk of future tragedies and fatalities occurring, would ask CQC and the Department of Health to give consideration to amending the current legal framework to ensure that care staff are all suitably trained in first aid and carry mobile telephones with which they can summon immediate assistance_if an incident occurs_wthout_having_to leave_the_side_of_the_person_ and due duty sadly, they are trying to assist
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Report details

Reference
2018-0207
Date of report
29 June 2018
Coroner
Peter Dean
Coroner area
Suffolk

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: 9 Oct 2018 (estimated).

Sent to

Care Quality Commission
Department of Health and Social Care

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