Source · Prevention of Future Deaths

Ahmed Tabeche

Ref: 2018-0143 Date: 11 May 2018 Coroner: Nadia Persaud Area: London (East) Responses identified: 1 / 1 View PDF

Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Date 11 May 2018

56-day deadline 26 Aug 2018 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

View full coroner's concerns

In the circumstances it is my statutory began duty to report to you: (1) The evidence given by the nursing staff and care staff who continue to work in the Care Home did not indicate a full understanding of the gravity of the risk of choking: Matters such as not causing offence to visitors or concern of turning the Home into a prison were quoted as reasons why food might not be fully checked. Care staff did not appear to appreciate that where a patient is at risk of choking, robust systems need to be in place to protect their lives (2)I note that action has been taken by the Care Home to place more posters around the Home, informing visitors to notify the nurse in charge before giving food to the loved ones_ do not consider that this is sufficient to address the concerns that have arisen in this case: The visitor who had been feeding Mr Tabeche confirmed that he focussed fully on Mr Tabeche when he attended. He did not read posters which were located inside Mr Tabeche' $ room_ He was not given any written information on the risk of choking; the type of food that Mr Tabeche should receive, or how he should be fed. More robust, written procedures around visitors and the provision of food may assist in providing a safer environment:

Responses

1 respondent

Twinglobe Other

5 Jul 2018 PDF

Action Taken

Twinglobe Care Homes has implemented changes across its group of homes, including a Choking Risk Assessment, Choking and Aspiration Care Plan, Aspiration Guidance, Nutrition and Fluid Chart, Nutritional Profile, leaflet for relatives/visitors, poster, Deprivation of Liberty Screening Checklist, Mental Capacity Assessment Record, Best Interests Decision Form, Visiting and Visitors Policy, Meal and Mealtimes in Care Homes Policy, and Food bought in by Visitors Policy. (AI summary)

View full response

TWINGLOBE CARE HOMES LIMITED Your Ref: AT ASP Sept 16 58 Abbey Road Enfield O5th July 2018 ENI 2QN 0208 370 1750 F: 0208 360 6484 Nadia Persaud www [winglobe com Walthamstow East London Coroners Court Queens Road Walthamstow London E17 8QP BY EMAIL ONL Dears Sirs, Re Inquest of Ahmed Amin Tabeche Date of Incident 15 September 2016 We write further to the Inquest of Mr Tabeche which concluded on 3rd April 2018 and the Regulation 28 Report to Prevent Future Deaths As a company we treat such matters very seriously and have moved swiftly to re-evaluate our policies and processes to ensure that we are providing the best possible care to our residents in the safest way possible We enclose with this letter an action plan that we have formulated in respect of this tragic incident and have sought to address the areas of concern that you raise as swiftly as possible In addition to the action plan we enclose: Action Plan for Regulation 28 Order Choking Risk Assessment (refers to box 1 of Action Plan) Choking and Aspiration Care Plan (refers to box 1 of Action Plan) Aspiration Guidance (refers to box 2 of Action Plan) Nutrition and Fluid Chart (refers to box 6 of Action Plan) Nutritional Profile (refers to box 7 of Action Plan) Leaflet for relatives and visitors (refers to box 8 of Action Plan) Poster (refers to box 9 of Action Plan) Deprivation of Liberty Screening Checklist (refers to box 10 of Action Plan) Mental Capacity Assessment Record (refers to box 10 of Action Plan) Best Interests Decision Form (refers to box 10 of Action Plan) Visiting and Visitors Policy Meal and Mealtimes in Care Homes Policy Food bought in by Visitors Policy ScOresi Aejeicsm Cidili Rezuefcred | nbe KTOS aesioi /N/ pI;

For the avoidance of doubt; these changes have been implemented across our group f Homes: Should the Coroner require further clarification on the enclosures, please do not hesitate to contact Julie Burton, Operation Director. Julie burton@twinglobe com alternatively Mobile 07966487987_

Report sections

Investigation and inquest

On 17/02/2017 , commenced an investigation into the death of Ahmed Amin TABECHE: The investigation concluded at the end of the inquest 3rd May 2018. The conclusion of the jury at the inquest was: The head injury sustained at St Ann's and the unsatisfactory assessments carried out during his stay at Aspray House contributed to the deterioration of his overall health and the insufficient guidance and supervision specifically relating to his feeding requirements all contributed to his death by choking:

Circumstances of the death

Mr Tabeche had suffered a traumatic brain injury whilst an in-patient at St Ann's Hospital on or around 30 January 2014_ His condition following the brain injury required full time care. He was admitted to Aspray Care Home on 2 March 2015. He was cared for on a unit with qualified nurses and care staff. He was blind, bedbound and required 2 carers to assist with personal care. He had suffered from swallowing dysfunction after the brain injury and required full assistance with feeding: The swallowing dysfunction had rendered him at risk of choking: The care plans and risk assessment in the Home recognised the risk of choking: The care plan also provided that "family and friends informed about it [swallowing difficulty] advice to give only soft pureed diet" . There was no clear direction as to who could feed Mr Tabeche_ There was no written record to confirm that visitors had been advised how to feed Mr Tabeche: On the 15 September 2016 Ahmed was being fed by one of his regular visitors. He was being fed vegetable soup, which contained pieces of vegetables. He to cough whilst being fed the soup and care staff intervened. He was noted to be choking and the choking protocol was followed: Resuscitation was carried out by nursing staff and then paramedics. Sadly he did not respond: He passed away at the Care Home at 1344 on 15 September 2016. The cause of death provided by the pathologist was 1a choking in a man with old traumatic brain injury.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action

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Report details

Reference: 2018-0143
Date of report: 11 May 2018
Coroner: Nadia Persaud
Coroner area: London (East)

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: 26 Aug 2018 (estimated).

Sent to

Twinglobe Care Homes Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.