Source · Prevention of Future Deaths
Margaret Rogerson
Ref: 2016-0155
Date: 21 Apr 2016
Coroner: M Jennifer Leeming
Area: Manchester West
0 responses identified · 3 indexed addressees
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AI-generated concerns summaryThe coroner noted a lack of staff training in patient feeding mechanisms, techniques, and associated risks, including no refresher training. Additionally, no training was available for family members on safe feeding practices.
Date
21 Apr 2016
56-day deadline
16 Jun 2016 est.
estimated from the report date
Responses identified
0 of 3
Coroner's concerns
The coroner noted a lack of staff training in patient feeding mechanisms, techniques, and associated risks, including no refresher training. Additionally, no training was available for family members on safe feeding practices.
View full coroner's concerns
During the Inquest evidence was heard that:
1. A Care Assistant giving evidence at the Inquest could not recall having been trained in the mechanisms of and techniques of how to feed patient; Particularly there was no evidence of any training relating to the risks involved in feeding patients nor as to the risks created by particular conditions from which patients were suffering: There was no evidence of there being any refresher training in the above matters;
3. There was no evidence of there being ay training available to family members and others close to patients in the above matters. There was clear and striking evidence that family members and others would appreciate such training available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones: There was also evidence that able to do this in professional and safe manner would be a great comfort to patient's relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient:
1. A Care Assistant giving evidence at the Inquest could not recall having been trained in the mechanisms of and techniques of how to feed patient; Particularly there was no evidence of any training relating to the risks involved in feeding patients nor as to the risks created by particular conditions from which patients were suffering: There was no evidence of there being any refresher training in the above matters;
3. There was no evidence of there being ay training available to family members and others close to patients in the above matters. There was clear and striking evidence that family members and others would appreciate such training available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones: There was also evidence that able to do this in professional and safe manner would be a great comfort to patient's relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient:
Report sections
Investigation and inquest
On the 20th of November 2015 I commenced an investigation into the death of Margaret Rogerson, 91 years, born November 1923. The investigation concluded at the end of the Inquest on the 20th April 2016. The conclusion of the Inquest was combination of Natural Causes and Accident:
Circumstances of the death
The circumstances as found by the were: - Margaret Rogerson, known as Peggy, who due to her Alzheimers Disease, was subject to a Deprivation of Liberty Safeguarding Authorisation. Peggy died on the 11th November 2015 at Victoria House, Mill View Care Home, Bolton of asphyxia due to aspiration of pureed food, whilst being fed, The progression of the Alzheimer's Disease, almost certainly caused her normal cough and epiglottis reflexes to no longer function, as explained by the Pathologist; which led to the aspiration and therefore the asphyxia: Way, Jury Mrs
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Report details
- Reference
- 2016-0155
- Date of report
- 21 April 2016
- Coroner
- M Jennifer Leeming
- Coroner area
- Manchester West
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: 16 Jun 2016 (estimated from the report date).
Sent to
- BUPA
- Mill View Nursing Home
- Right Honourable Jeremy Hunt MP