Source · Prevention of Future Deaths
Barbara Haley
Ref: 2018-0095
Date: 3 Apr 2018
Coroner: Rachel Galloway
Area: Manchester (South)
Responses identified: 0 / 3
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Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Date
3 Apr 2018
56-day deadline
12 Aug 2018 est.
Responses identified
0 of 3
Coroner's concerns
Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
View full coroner's concerns
Whilst these matters did not contribute to Barbara Hayley's death; they did reveal matters giving cause for concern in respect of the risk of future deaths: Mrs was on a soft diet (described as a "fork-mashable diet" in evidence) Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff In particular , on one occasion toast was found in her room. On another occasion, staff had apparently suggested to a family member that chocolate could be given to Haley the days Haley Haley Mrs
During Ihe course of her evidence_ (Home Manager) explained that Mrs Haley was assessed as being atrigh Risk of choking and scored highly on the risk assessment that had been carried out Despite this, Mrs would be Ieft alone in her room t0 eat because stated) she did not to have staff present when she was eating; she would then refuse to eat; We heard evidence from a manager at another home that Mrs would eat when she was in the dining room with other residents, where staff could also observe her, It was of concern that Mrs was being left alone in her room to eat when she had been assessed as being at high risk of choking:
During Ihe course of her evidence_ (Home Manager) explained that Mrs Haley was assessed as being atrigh Risk of choking and scored highly on the risk assessment that had been carried out Despite this, Mrs would be Ieft alone in her room t0 eat because stated) she did not to have staff present when she was eating; she would then refuse to eat; We heard evidence from a manager at another home that Mrs would eat when she was in the dining room with other residents, where staff could also observe her, It was of concern that Mrs was being left alone in her room to eat when she had been assessed as being at high risk of choking:
Report sections
Investigation and inquest
On the 23r October 2017 an inquest was opened into the death of Barbara Haley. The inquest took place on the 29uh March 2018 and the conclusion was one of Natural Causes The medical cause of death was: Ia Aspiration Pneumonia 1b Alzheimers Dementia
Circumstances of the death
On the 13h October 2017 or in prior, Mrs had inhaled either vomit; saliva, food or liquid whilst resident at Hilltop Court Care Home. This led to the development of a chest infection and her condition deteriorated suddenly on the morning of the 13th October 2017 . An ambulance was called and she was transported to Stepping Hill Hospital but suffered a cardiac arrest on route and passed away at Stepping Hill Hospital on the morning of the 13th October 2017_
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
- 2018-0095
- Date of report
- 3 April 2018
- Coroner
- Rachel Galloway
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Aug 2018 (estimated).
Sent to
- Care Quality Commission
- Harbour Health Care Limited
- Hilltop Court