Brian Parry · Prevention of Future Deaths report

On 9 November 2021 an investigation commenced into the death of Brian Parry, aged 88 years. The investigation concluded with an inquest heard on 27 July 2022. The Coroner returned a narrative conclusion

Brian Parry lived at Brunswick Retirement Village, Station Road, Woodhouse, Sheffield. On 3 November 2021 he was eating in the on-site restaurant when he began to choke

Back slaps were administered by staff, and he was placed on the floor in the recovery position. Assistance from additional staff was requested via the emergency cord in the restaurant

Additional staff attended the restaurant. The emergency services were called by one of those members of staff, six minutes after the emergency cord was activated. CPR was administered by staff on the instruction of the emergency services

On the arrival of paramedics, Brian Parry was not breathing. Paramedics removed food from his airway and began advanced life support which was unsuccessful, and he was pronounced deceased

The narrative conclusion given was as follows:

Brian Parry died at the Brunswick Retirement Village, Station Road, Woodhouse, Sheffield on 3 November 2021 after his airway became obstructed by food. There were missed opportunities to call emergency services between Brian Parry beginning to choke and the call being made

Had emergency services attended sooner, it is likely the food would have been removed and advanced life support administered. It cannot be said whether this earlier medical attention would have prevented his death

I am concerned that unless staff are trained to call the emergency services immediately, further delays will occur in the administration of potentially lifesaving treatment

I am concerned that when the emergency cord was pulled, the request for assistance went to care staff who were between 1 and 4 minutes away from the restaurant rather than to all staff, some of whom were near by

I am concerned that despite all staff having basic first aid training, evidence was given at the inquest that not all staff are confident using their training

I am concerned that there is not an advanced first aider on site available to be called upon in an emergency

It is my opinion there is a risk that future deaths may occur if these concerns are not addressed