Ivy May DIXON · Prevention of Future Deaths report

On 11 October 2024, an investigation was commenced into the death of Ivy May DIXON, aged 96 years at the time of her death.

The investigation concluded at the end of an inquest heard by me on 28 January and 28 March 2025.

I conclusion of the inquest was a short narrative conclusion.

The medical cause of death was:

1a asphyxia
1b choking on food
II essential hypertension and type 2 diabetes mellitus

The circumstances of Mrs Dixon’s death are encapsulated within the narrative conclusion from the Inquest, which was as follows:

“Ivy Dixon choked on food causing cardiac arrest while being fed by staff in her room at Acorn Lodge Care Home on 6 October 2024. Carers called an ambulance but did not perform CPR when Mrs Dixon became unresponsive prior to an ambulance arriving.

Mrs Dixon had a DNACPR order in place, which would not apply to an episode of choking. This is because choking is a potentially reversible cause of cardiac arrest.

Care staff told the paramedics that Mrs Dixon had not been fed that evening. This was not true. This led paramedics to conclude that Mrs Dixon’s cardiac arrest did not have a reversible cause. It is unclear whether, if paramedics had been given a correct account of events, the outcome would have been any different.”

1. The healthcare assistant who had been with Mrs Dixon on the evening of 6 October 2024, clearly referred in her statement to the patient having been fed. Shortly thereafter the healthcare assistant heard “a noise” coming from the patient’s chest and so she called for the assistance of a nearby nurse. Two nurses attended and made the reasonable assumption that the patient was choking. Treatment was administered and a set of vital observations showed that the patient’s oxygen saturations were 87%. On this basis, nursing staff called for an emergency ambulance: the London Ambulance Service (LAS) call handler was told that the patient was “choking” albeit she was breathing and conscious at that time.

Despite this, once LAS staff arrived at Acorn Lodge Care Home, the Care Home staff told paramedics that they had been attempting to feed the patient, but the patient started to gasp before any food was given to her, meaning they were unable to feed her.

This raises concerns about the communication and integrity of the staff members at the Care Home in their provision of care to the patient. I did not receive any reassurance that this concern has been addressed.

2. While the patient was breathing and conscious at the time of the 999 call, when LAS staff attended six minutes later, the patient was not conscious, not breathing, had no palpable pulse, and was critically unwell in confirmed cardiac arrest. However, despite this, staff from the Care Home were not undertaking CPR. The DNACPR would not have applied in this case, because choking is a potentially reversible cause of cardiac arrest, which the Care Home’s manager confirmed in her evidence.

This raises the concern that staff (healthcare assistants and nursing staff) at the Care Home may have previously unidentified training needs and/or lacked the clinical skills/knowledge to provide emergency care.