Source · Prevention of Future Deaths

William Wilson

Ref: 2017-0186 Date: 12 Jun 2017 Coroner: Christopher Murray Area: Manchester (South) Responses identified: 0 / 1 View PDF

The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.

Date 12 Jun 2017
56-day deadline 4 Oct 2017 est.
Responses identified 0 of 1
Other related deaths

Coroner's concerns

AI summary
The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene_ (Z)The Manager of the Church Inn was unable to inform me of the System for alerting the first aider to ##DW<<corAddress > Tcl ##DW<<corTcl>> Fax ##DW<<corFor> ward The problem to ensure he attended the scene_ (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson: ##DW<<corAddress > > Tel ##DIV<<corTel?> Fox ##DW<<corFar > any on

Report sections

Investigation and inquest
On 13/02/2017 commenced an investigation into the death of William Joseph WILSON. The investigation concluded at the end of the inquest 8th June 2017. The conclusion of the Inquest was Mr Wilson was enjoying a meal at the Church Inn on the 26th November 2016 when he suddenly choked as 3 result of a piece of steak becoming lodged in his throat: He was asphyxiated and suffered a fatal hypoxic brain injury and died at The Meadows, Stepping Hill Hospital on the Znd February 2017_ Hypoxic Brain Damage Choking Hypertension
Circumstances of the death
Date Admitted: 26/01/2017 Consultant responsible for patient at time of death: Patient brought in by ambulance to the emergency department on the 26/1/2017 at 14.58 following a choking on a large piece of steak. Attended by paramedics within 4 minutes of choking and was resuscitated following which he expelled a large piece of steak. Unfortunately; he sustained hypoxic brain damage and was in coma a5 a result and following intensive care review it was considered that this was a terminal event and he was transferred to medical ward for end of life care: He was treated for aspiration pneumonia but deteriorated further with no improvement in his conscious levels. Following discussion with his daughter it was considered that palliative care would be provided in Bluebell where he died on the 2/2/2017 . Relevant PMH Hypertension
Action should be taken
In my opinion action should be taken to prevent future deaths and believe vou have the power to take such action:

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Report details

Reference
2017-0186
Date of report
12 June 2017
Coroner
Christopher Murray
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Oct 2017 (estimated).

Sent to

Church Inn

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