Joan Howard · Prevention of Future Deaths report

In April 2019 I commenced an investigation into the death of Joan Howard. The investigation concluded following an inquest on 4 February 2020 where the conclusion was:

• Narrative Conclusion

On 10 April 2019 Joan Howard choked on a sandwich provided to her at hospital. The sandwich should not have been provided to Joan and was contrary to appropriate professional advice. Joan’s death was therefore contributed to by neglect

Joan Howard was admitted to the Northern General Hospital on 4 April 2019. She had a previous medical history of oral cancer and as a result had difficulties with communication and with eating and drinking. She had repeatedly been assessed by the speech and language therapy team and was assessed as requiring level 2 fluid and level 6 food.

She had previously been a patient at the Royal Hallamshire Hospital and was given appropriate diet and had been discharged to a care home who had been cognisant of her dietary requirements.

Upon admission the Northern General Hospital for unexplained seizures, her dietary requirements were not appropriately managed resulting in her choking to death on a sandwich which should not have been given to her. This was at least the third occasion when a food item which should not have been provided to Joan had been.

Joan was at the end of her life upon admission to the Northern General Hospital however it is acknowledged by the team investigating her death that she is not likely to have died how and when she died but for the inappropriate provision of a sandwich.

a) The SALT input into Joan’s care was exemplary. She had appropriate assessments and following a visit on the ward the day after her admission appropriate clear posters were placed above Joan’s bed confirming what nutrition she could have. Despite these posters, on two occasions Joan was provided with inappropriate food.

b) The care home from which Joan was admitted had provided appropriate advice about her nutritional requirements which was available to the hospital upon admission but which was not acted upon.

c) The Senior Sister on the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff.

d) The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to understand what was meant by level 2 fluids and level 6 food. This was not the case in practice.

e) The Senior Sister on the ward confirmed that where someone had capacity and made an unwise choice which contradicted the indication from speech and language therapy, she would expect staff to escalate this to the clinical team to have a discussion with the patient. This was confirmed by the Matron responsible for the presentation of the Serious Incident Investigation at Court however in Joan’s case, if staff were aware that the choice of two sandwiches and a piece of cake were inappropriate for Joan, they did not escalate this to the clinical team.

f) Joan was sent to an outpatient appointment with no thickener for fluids meaning that prior to her deterioration on the 9 April 2019 she had no access to fluids for the duration of her outpatient appointment and waiting.

g) Temporary posters for Joan’s nutritional needs were placed above Joan’s bed by staff once they became aware of the need for Joan to have a special diet. This was over 12 hours after her admission to the ward and therefore covered an evening meal, breakfast and lunch, during which inappropriate diet could have been given to Joan and definitely was at lunch time. This was despite information being available to the Ward from the care home Joan had been brought in from about her nutritional requirements. Additionally, the Royal Hallamshire Hospital where she had been discharged from earlier the same day before admission to the Northern General Hospital, had information about her nutritional requirements. It wasn’t until the family noticed that Joan had been given a sandwich at lunch time on 5 April 2019 that staff placed temporary posters above her bed.

h) I found that on the basis of the evidence I heard at inquest, neglect had played a significant contributory part in Joan’s death as a result of the issues described above. I found that this was largely a cultural and communication issues, particularly once appropriate signage was placed above Joan’s bed and errors were still made on at least two further occasions.