PAMELA JOYCE THURSTON · Prevention of Future Deaths report

On 13 July 2015 I commenced an investigation into the death of PAMELA JOYCE THURSTON aged 78. The investigation concluded at the end of the inquest on 29 February 2016. The conclusion of the inquest was accidental death due to 1a) Bronchopneumonia; 2. Alzheimer's Disease.

Mrs Thurston died at Norfolk and Norwich University Hospital on 7 July 2015 after choking on some toast she was given at Cedar Care Home in Yelverton, Norfolk two days earlier.

Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so.

Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect.

The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift.
On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics.

Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital.

It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later.