HM Coroner for Manchester South, Ms Alison Mutch, returned a narrative verdict of neglect after a four-day inquest which concluded on 28 June 2018 into the death of 68-year-old Jane Olive Parker.
Mrs Parker choked to death after being given an inappropriate meal at Fir Trees Care Home in Dukinfield, Tameside, Greater Manchester in 2016.
The Coroner also said that she would send a Preventing Future Deaths (PFD) report to the government minister with responsibility for care and the Care Quality Commission (CQC) since she was persuaded there was a risk of other deaths occurring in similar circumstances.
Mrs Parker had dementia and poor mobility. She had moved to Fir Trees in early July 2016 from a previous home, Millbrook, run by the same provider, HC-One. Prior to her death, she had a number of food-related choking episodes. She had been admitted to Tameside General Hospital in 2015 after a choking incident involving gammon that she was fortunate to survive.
She was referred to the speech and language therapy (SALT) team for an assessment of her swallowing problems. They advised that she should remain on a Stage 3 diet (food that is semi-solid, soft or pureed and easily digested).
The inquest learned that when Mrs Parker was transferred to Fir Trees, staff did not assess her directly, relying instead on the care plan from Millbrook. Contrary to good practice, no new care plan was put in place and crucially the existing care plan made no mention of the choking episodes and erroneously stated that Mrs Parker should be on a Stage 4 diet.
On 24 August 2016 Mrs Parker was offered a choice of soup or chicken nuggets and chips for her evening meal, served in her bedroom rather than the main dining area. She chose the nuggets and was left to eat unsupervised.
About 40 minutes later care workers discovered Mrs Parker to be unresponsive with a fixed stare. She was pronounced dead less than an hour after being given that evening meal. The pathologist’s post mortem was clear cut in identifying the cause of death as asphyxiation, aspiration of food and dementia. In delivering her verdict, the Coroner commented:
‘I am satisfied that Mrs Parker was not consistently given the appropriate food and whilst incidents that indicated her swallow was compromised were noted, there was no escalation or reporting to the manager. The appropriate conclusion is that the deceased died from recognised complications from aspiration of food, contributed to by neglect.’
Chris McKinney, a partner at Shoosmiths who represented the family at inquest, said:
‘The inquest revealed failures of care as well as poor communication and record keeping in this tragic case. The Coroner’s conclusion of neglect vindicated the family’s belief that their mother choked to death by attempting to eat a meal that was entirely inappropriate for her.’
Jane’s son, Richard Parker, said:
‘The inquest gave us a lot of answers, but we still feel completely let down by HC-One. Staff should have known about her diet and should have been aware that her dementia meant that she didn’t have insight into the risks posed by choosing the meal that killed her. We still feel that our mother’s death could and should have been avoided.’
Sarah Cunliffe, a solicitor specialising in care home neglect and abuse cases at Shoosmiths, who would manage any civil claim the family may now intend to pursue, added:
‘The verdict of neglect clearly adds weight to a potential civil claim for compensation, however, like so many others in this tragic position, the family’s motivation is not financial. Compensation in these cases is never huge and of course it won’t bring back their mother. What the family want, having got answers to most of the questions they had at inquest, is to make sure that this cannot happen to somebody else’s loved one.’