Source · Prevention of Future Deaths

Keith Barton

Ref: 2013-0330 Date: 6 Dec 2013 Coroner: Patricia Harding Area: Mid Kent and Medway Responses identified: 1 / 1 View PDF

There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, hindering further specialist reviews.

Date 6 Dec 2013

56-day deadline 20 Apr 2014 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

and The eating him

During course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken: : (1) That clarification as to the level of supervision and monitoring was not sought from the speech and language therapist in a case where the recommendation required clarification (2) That external training in relation to dysphagia awareness which had been put in place following the death of Mr. Barton could not be delivered to all staff members because of constraints on the number of places available (which could potentially be resolved by in-house training) (3) That incident reports were not completed and therefore & further SALT review had not been triggered (this has been addressed by the nursing home and does not require further action to be taken) (4) That residents at risk of choking were subject to periodic checks (this has been addressed by the nursing and does not require further action to be taken)

Responses

1 respondent

Life Style Care Other

7 Mar 2014 PDF

Action Taken

Lifestyle Care booked dysphagia training for staff in February and March 2014 and a Nutrition and Hydration course in March 2014. They received confirmation from SALT that they will now be charging £125 per session and sessions can be booked from the end of March. (AI summary)

View full response

Dear Senior Coraner Harding am writing in response tolyour Prevention of Future Deaths Report following the Inquest touohing on the death of Mr Keith Barton; First, would Iike to again express my sincere condolences to the family and friends of Mr Barton: Your report ralses four imatters of concern; namely: Clarificatlon ofirecommendations from the Speech and Language Therapist (SALT) Delivery of training in relation to dysphagia awareness Completion of incident repons_ The process for checking residents at risk of choking: Your report confirmg that You were satisfied, at the conclusion of the inquest; that Gardens had in place appropriate measures in relation to items 3 and 4 and that no additional action neede to be taken to address these concerns, deal with your reraining concems below: Clarification of recommendations ftom SALI Mr Barton had a diagnosis of Picks disease. As a result of his condition he had a history of pocketing food and not swallowing: Whilst at Ashley Gardens he was assessed as being at risk of choking because of his condition and he was seen by SALT on 23" August 2012 The written referral received 'from SALT confimed Ihat Mr Barton required supervision and monitoring whilst In accordance with usual practice at Gardens this was interpreted as meaning checks rather than constant supervlslon: The evdence at the Inquest was that no member of staft from the home had checked on Mr Barton whilst he was eating breakfast on the moming of 5 February 2013, The SALT therapist gave evidence stating that the written recommendation sent to Ashley Gardens on 16"" October 2012 meant constant supervision by someone Sitting with Mr Barton or in close proximlty: This was not Ashley Gardens' underatandlng ofthe recammendation made: Whilst it is accepted that no dlanfication was sought fram the SALT in relation t0 the recommendation, would have expectedithe woring of the recommendation ta be specific and clear if it was their view that constant supervision was required LIFE STYLE CARE Q0Ll) FLC RBGENT HOUSE; THEOBALD STREEL ELSTREE BOREHAMWOOD, HERTS WDS 4R5 TEL: (0207 8327 L3BU FAX: (020) 8377 1340 Emniil: admin@lilatyleanco.uk Wcbrite; wiwllfestyleczremuk Rcgistered No: 7709694 Ashley put eatng: Ashley period

PifeStyle Care (2011) PL met with SALT on 17 January 2014 in order to discuss your concems In respect of the ambiguity of their recommendation In this case The following action plan has been egreed: (a) We will ensure that all SALT recommendations are seen by the senior nurse On duty 80 that & senior member of staff cank deterine whether any clarification is required (b) SALT will ensure that where supervision ig recommended approprate detail of the expected supervision Is given Dellvery ot tralning in relation to dysphagia awareness Ashley Gardens have requested training from SALT however have confirmed that only 2 members of staff from Ashley Gardens are permitted to attend each training session: Ashley Gardens have offered to host the SALT tralnlng however they have been infarmed that they are still only permitted to have 2 members Of statt: Unfortunately the result is that it would take a significant period of time for all members of Staff to receive dysphagia awareness training: met with SALT on 17 January 2014 in order to discuss your concerns In respect of the delivery of training in relation to dyephagia awareness was informed that SALT was in the process of agreeing the content of future dysphagia training for nursing home staft This was so that they can have the training validated by the Trust to ensure the cantent and quality is of a high and consietent standard across the whole Trust 'area SALT confined t0 me thaf this procecs would be completed by the end of February 2014 80 that training could start offered again from March 2014. As a result of the above sourced some dysphagia awareness training from a private SALT therapist. She has experience of delivering dysphagia training t0 difference healthcare professions across nursing homes; day centres and hospltals. Her training is based on literature; published research and her own experience in the Sector: She has over 12 years of clinical experience as a speech and language therapist and is now an indeperdent practitioner. She is registered with The Royal College of Speech and Language Therapists and Healthcare and Professions Council: The sessiong Bhe provides' run for 60 minutes and cover the following topics; The normal swallow; What can go wrong; Signs and symptoms of dysphagia; How difficulties are assessed; Treating and compensating for dysphagia The sessions are interactive with practical exercises and a Short video clip. The session can be given to up to 20 people at one time: LIESTYLE CARE (2012) PLC REGENT HOUSE Page 2 of3 THFOBALD STRBET BLSTREE BOREHAMWOOD. HEKTS WD6 4RS TEE (OI &327 1330 FAx: (02D) 6327 Email; admin@llf-lylecare muk Websitc; wwwlllestykcare co.uk Registnd No. 7709694 they being 1340

Lo_ L6'Ju UI - 70CU(o346170 Fage 4/4 OieStyle Care (2011) PLC booked a seesion which was completed on 15"" February 2014 for 15 members of stalf and another sesslon has been aranged for March 2014 which Wll be anended by 20 members of staff also booked a Nutrition and Hydration course which was completed by 15 memberg pf staff oh 5" March 2014. This was a more generic training covering feeding do not intend book any future eesslons of this training aslit was not as beneficial as the dysphagia training: received a response from SALT on 6" March 2014 which confimed they will naw be charging E125 per gession and sessions can be booked from the end af Maroh: was given verbal confination trom the SALT Manager that this will be course just nun for Ashley Gardeng and we can have approximately 10 to 15membere of staff on each session However; was intormed that thig is subject to written confirmation_ Should Ihere prove to be ahy issues causing delays in the completion ofthe SALT training will book more sessions with the above private SALT therapist in order to ensure that the training of staff is completed as quickly a3 possible: Please Iet me know if I can be of any further assistance.

Report sections

Investigation and inquest

On the 3rd December 2013 commenced an investigation into the death of Keith Barton; 77 years_ investigation concluded at the end of the inquest on the 4th December 2013. The conclusion of the inquest was that Keith Barton died as the result of an accident, the medical cause of death being 1a. Inhalation of food II Dementia. Box 3 was completed that Keith Barton suffered from Alzheimer's disease and dementia. He had a history of pocketing food and not swallowing and was therefore at a risk of choking: He was assessed by a speech and language therapist as requiring supervision and monitoring whilst eating; At the nursing home supervision was by way of periodic check: On the morning of the 5"h February 2013 he choked and died whilst eating his breakfast in his room on his own. There is no evidence that he was checked while eating his breakfast

Circumstances of the death

Keith Barton had a history of Alzheimers disease and dementia and as a result had a history of pocketing food and not swallowing_ He was therefore at risk of choking: Whilst resident at Ashley Gardens nursing home he had been assessed by a speech and language therapist (SALT) 2s requiring supervision and monitoring While eating: It was not clear whether this was communicated at the time of the assessment but was confirmed in writing at a later date. This was interpreted by staff at the nursing home as intermittent rather than constant supervision and when breakfast in his room he was subject to periodic checks. The majority of meals were taken in a communal area. There were 3 previous documented choking incidents prior to Mr: Barton's death, on each occasion staff were on hand to assist and no harm occurred: On the 5" February 2013 Keith Barton was eating breakfast in his room when he choked and died. There was no evidence that Mr; Barton had been checked whilst eating his breakfast by any of the staff on duty. The SALT gave evidence at the inquest that by supervision and monitoring_she meant constant supervision by someone sitting with or in close proximity: The nursing home did not ask for clarification of the recommendations communicated in the letter from the SALT which was somewhat ambiguous

Action should be taken

In my opinion action should be taken to prevent future deaths (in respect of (1) and (2) above) and believe you have the power to take such action:

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Shared signals

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Report details

Reference: 2013-0330
Date of report: 6 December 2013
Coroner: Patricia Harding
Coroner area: Mid Kent and Medway

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Apr 2014 (estimated).

Sent to

Ashley Gardens Nursing Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.