Stephen Anthony MAGUIRE · Prevention of Future Deaths report

On 21 September 2020 I commenced an investigation into the death of Stephen Anthony MAGUIRE. The investigation concluded at the end of the inquest on 27 April 2021 . The conclusion of the inquest was that Mr Stephen Anthony MAGUIRE died due to an accident.

Mr Stephen Anthony MAGUIRE was detained at Dartmouth House 70-72 Handsworth Wood Road, Handsworth Road, Birmingham (run by Options for Care Limited) pursuant to s.3 Mental Health Act 1983 for treatment of chronic treatment resistant paranoid schizophrenia. At lunchtime on 14/09/2020, Mr Stephen Anthony MAGUIRE was in the lounge area with other residents where he was seen to be about to start eating his lunch, when he got up from the table, walked a short distance and then collapsed. Staff began CPR whilst an ambulance was summoned, and it was noted his chest was not rising with ventilation. He had a difficult anatomy due to a large tongue and adipose neck, and upon examination using laryngoscope, paramedics reported that his airway presented as a Cormack-Lehane grade 4 view. Multiple and repeated efforts were attempted to troubleshoot and clear his airway in accordance with Joint Royal College Ambulance Liaison Committee Guidelines. A period of roughly 30 minutes passed where he was without oxygen before video laryngoscope revealed a mass of chewed meat at the base of his tongue deep in his larynx. Despite the obstruction being removed with forceps and resuscitation being continued, he was deemed to have sustained an unsurvivable brain injury due to suffering 30 minutes of absolute hypoxia. Treatment was stopped, and he died at 13:40 on 14/09/2020.

Following a post mortem, the medical cause of death was determined to be:

1a CHOKING

1b

1c

II

1. I heard evidence that the PIT alarm used by staff member, ████████, did not work when pressed. I heard evidence this was alarm was checked after the incident and found to not have been charged. I heard evidence from the ████████ ████████ that Options for Care Limited have a system whereby it is the night staffs’ responsibility to check and charge the PIT alarms overnight, and it is the responsibility of the day care staff to check that their PIT alarms are charged and operational when they come on shift in the morning ("the charging system"). Somehow, this charging system failed. Although not causative in Mr Stephen Anthony MAGUIRE's inquest, if a member of staff is unable to utilise their own PIT alarm in an emergency, this creates an obvious risk of death to both service users and staff alike.

2. I heard evidence that ████████ was an agency worker working for Options for Care at the time of Mr Stephen Anthony MAGUIRE's death, and there was a suspicion (but which could not be proven) that they may have either been unaware of the charging system, or made a simple error. Although not causative in Mr Stephen Anthony MAGUIRE's death, if members of staff (both full time and agency workers alike) are unaware of the charging policy, or are not trained and reminded in the same, there is the risk of death if a member of staff is unable to utilise their own PIT alarm in an emergency due to the same not being charged.