Source · Prevention of Future Deaths

Geraldine Butterfield

Ref: 2017-0022 Date: 25 Jan 2017 Coroner: Anna Crawford Area: Surrey Responses identified: 0 / 1 View PDF

Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.

Date 25 Jan 2017
56-day deadline 16 Apr 2017 est.
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.
View full coroner's concerns
Having heard evidence number of members of the nursing staff, I am concerned that not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking, so as to be able to effectively implement it in the future am also concerned that not all staff members have a sufficient understanding of when potentially life-treatment should be provided to individuals in respect of whom a DNAR order is in place Not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking s0 as to be able to effectively implement it in the future: Not all staff members have a sufficient understanding of when potentially life-treatment should be provided to individuals in respect of whom a DNAR order is in place Consideration should be given to whether any steps, including further training, can be taken to address the above concerns.

Report sections

Investigation and inquest
The inquest into the death of Mrs Butterfield was opened on the 5 August 2015 and was resumed and concluded on the 24th January 2017. The cause of death was: la - Asphyxia due to food inhalation. The inquest concluded with a narrative conclusion,
Circumstances of the death
Mrs Butterfield was a resident at Collingwood Grange nursing home in Camberley: The nursing home is run by BUPA Care Services Limited and Mrs Butterfield's placement was funded by Surrey County Council On 25 July 2015 Mrs Butterfield was her lunch in the dining room when she was noticed to be slumped over in her wheelchair: A nurse attended and checked Mrs Butterfield's mouth and did not see any food, she positioned her S0 as to maintain her airway and slapped her on the RT4563 eating back She then arranged for Mrs Butterfield to be wheeled to her bedroom where she was placed in the recovery position on her bed Another nurse then repeatedly slapped Mrs Butterfield on the back and used a suction machine to remove food from her mouth and the opening of her throat; The court heard evidence that the suction machine was not capable of removing food from Mrs Butterfield' s Mrs Butterfield was then placed on the floor in preparation for carrying out Cardio-Pulmonary Respiration (CPR): However, CPR was not ultimately attempted because Mrs Butterfield had a valid Do Not Attempt to Resuscitate (DNAR) order in place, and her death was confirmed by attending paramedics at 13.09. The court heard evidence that repeated back blows were not attempted until Mrs Butterfield had been transferred to her room and placed on the bed and that no attempt was made to carry outany abdominal thrusts, in contravention of the BUPA policy on choking:
Copies sent to
Ihave sent a copY of this report to the following: 2_ Surrey Heath Locality Team, Surrey County Council

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Report details

Reference
2017-0022
Date of report
25 January 2017
Coroner
Anna Crawford
Coroner area
Surrey

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: 16 Apr 2017 (estimated).

Sent to

Collingwood Nursing Home

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