Dorothy Mavis Clarkson · Prevention of Future Deaths report

On 29th July 2013 I commenced an investigation into the death of Dorothy Mavis Clarkson, aged 78. The investigation concluded at the end of the inquest on 10th September 2014. The conclusion of the inquest was that the cause of death was 1a Respiratory arrest due to 1b Inhalation of food with significant contributory factors at 2 Ischaemic heart disease, valvular heart disease and previous intracerebral haemorrhage.
The conclusion in Box 4 was that Dorothy Mavis Clarkson died an accidental death, contributed to by neglect.

DMC choked on a large piece of meat while eating her meal at Longton Nursing and Residential Home on the 25th July 2013 at approximately 1255hrs and became unresponsive. Initial attempts at resuscitation by staff at the home were unsuccessful, but paramedics who arrived shortly after were able to clear her airway and re-establish circulation. She was taken to Royal Preston Hospital where her condition deteriorated and she died on the 27th July 2013.

(1) the procedure by which food is provided and presented to residents who require food to be prepared in a certain way and who need assistance by virtue of their physical or mental condition; and
(2) a lack of training appropriate to nursing staff working in a nursing home being undertaken by qualified nursing staff to satisfy the on-going professional development requirement of the Nursing and Midwifery Council.