Joan George image
Credit: Stamford Mercury

A three-day inquest at the Cathedral Centre in Lincoln has found that a string of “inadequacies” at a Lincolnshire-based care home led to an elderly woman choking to death on a sandwich.

The jury foreman at the inquest of Joan George, who died on the 28th of September 2016 at Abbey Court Care Home, told the Stamford Mercury that there were numerous inadequacies in training at the Home.

The narrative verdict was delivered at the end of the inquest, led by Marianne Johnson, Assistant Coroner for Lincolnshire.

Joan, 73, was admitted to Abbey Court Care Home on the 24th of August 2015. Her inquest opened with various statements, including one from a pathologist who confirmed there was evidence of food obstructing her airways. A post-mortem examination concluded that the cause of death was choking, dementia and cerebral contusions.

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The oral evidence began with Abbey Court Care Home Care Assistant Ahibo Attekeble. Ahibo, who was feeding Joan the sandwich she choked on, said she had not received specific training on what to do if someone started choking.

After eating most of the sandwich, which had been torn up into small pieces, Joan, who was in bed at the time, began choking. The inquest was told she started making a grunting-like noise and was reaching out with her hands. Ahibo then called out for her colleagues and went to press the emergency button.

Neil Wright, who was the duty nurse at the Care Home that evening, responded to the emergency bell. He explained that he did back-slaps and the heimlich manoeuvre to no avail before calling 999, where the operator instructed him to perform stomach presses, but these also did not work.

When the operator instructed him to do CPR, he said Joan had a ‘do not resuscitate order’, so CPR was not performed.

Paramedics pronounced Joan dead at 10.54pm, shortly after arriving at the premises.

The inquest also heard from care assistants Inot Geanana and Luke Masterson, who responded to the call for help; they managed to get some pieces of the sandwich out of her throat.

On the second day, Annabel Marshall, Deputy Manager at Abbey Court, said that after Joan came back to the home from a two-day stay in hospital following a fall on the 17th of September, the nurses had assured her there were only problems with her mobility.

It was known that Joan ate slowly and required assistance with food, but there was no evidence of choking or swallowing difficulties before her death.

However, a choking risk assessment carried out on the 21st of September, found that although still considered a low risk, Joan’s score had increased from two to 13, but this was not reflected in the care plan.

Annabel also said that Ahibo had not read the 73-year-old’s care plan or attended the shift handover.

Sarah Mann, Associate Director of Nursing at Priory Adult Care, which owns Abbey Court, said procedures and staff training have improved after Joan’s death. She said staff now had basic life support training once a year and this included dealing with residents who were choking. Handovers between staff were also improved.

A new assessment called ‘supporting service users with swallowing difficulties’ had also been implemented along with a greater attention to keeping documentation up-to-date.

There was also clearer information produced about each resident so the care assistants were more aware of residents’ requirements.

Lincolnshire County Council also visited the Home after Joan’s death to propose a number of recommendations to the care home for general improvements. These included: further staff training in writing reports; communicating with relatives more effectively; clarification in regards to do not resuscitate orders and further training in writing comprehensive care plans.

The Home has confirmed that it has since put measures in place to address all of these recommendations.

Joan’s family concluded the second day’s session with an emotional tribute.

The inquest ended with the narrative verdict on the 27th of March 2019.

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