Source · Prevention of Future Deaths
Dorothy Clarkson
Ref: 2014-0465
Date: 26 Sep 2014
Coroner: Simon Jones
Area: Preston & West Lancashire
Responses identified: 0 / 3
View PDF
Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Date
26 Sep 2014
56-day deadline
28 Nov 2014
Responses identified
0 of 3
Coroner's concerns
Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
View full coroner's concerns
(1) the procedure by which food is provided and presented to residents who require food to be prepared in a certain way and who need assistance by virtue of their physical or mental condition; and (2) a lack of training appropriate to nursing staff working in a nursing home undertaken by qualified nursing staff to satisfy the on-going professional development requirement of the Nursing and Midwifery Council: the eating July being
Report sections
Investigation and inquest
On 29ih July 2013 commenced an investigation into the death of Dorothy Mavis Clarkson, aged 78. The investigation concluded at the end of the inquest on 10' September 2014. The conclusion of inquest was that the cause of death was 1a Respiratory arrest due to 1b Inhalation of food with significant contributory factors at 2 Ischaemic heart disease, valvular heart disease and previous intracerebral haemorrhage: The conclusion in Box 4 was that Dorothy Mavis Clarkson died an accidental death _ contributed to by neglect:
Circumstances of the death
DMC choked on a large piece of meat while her meal at Longton Nursing and Residential Home on the 25th July 2013 at approximately 1255hrs and became unresponsive. Initial attempts at resuscitation by staff at the home were unsuccessful, but paramedics who arrived shortly after were able to clear her airway and re-establish circulation. She was taken to Royal Preston Hospital where her condition deteriorated and she died on the 27th
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.
Similar PFD reports
Related inquiry recommendations
Muckamore Abbey Inquiry
Co-production training
Muckamore Abbey Inquiry
Human rights-based restrictive practices training
Al-Sweady Inquiry
Interpreter Availability
Mid Staffs Inquiry
Focus on culture of caring
Mid Staffs Inquiry
Practical hands-on training and experience
Mid Staffs Inquiry
National standards
Mid Staffs Inquiry
Nurse leadership
Mid Staffs Inquiry
Nurse leadership
Bristol Heart Inquiry
Mandate specific communication skills training for professionals caring for children and parents
Bristol Heart Inquiry
Integrate patient-professional partnership principles into all healthcare professional education and training
Report details
- Reference
- 2014-0465
- Date of report
- 26 September 2014
- Coroner
- Simon Jones
- Coroner area
- Preston & West Lancashire
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: 28 Nov 2014.
Sent to
- Care Quality Commission
- MPS Investments Ltd
- Nesbit Law Group [Solicitors for the Clarkson family]