Margaret Rogerson · Prevention of Future Deaths report

On the 20th of November 2015 I commenced an investigation into the death of Margaret Rogerson, 91 years, born 29 November 1923. The investigation concluded at the end of the Inquest on the 20th April 2016.

The conclusion of the Inquest was a combination of Natural Causes and Accident.

The circumstances as found by the Jury were:-

Mrs Margaret Rogerson, known as Peggy, who due to her Alzheimer’s Disease, was subject to a Deprivation of Liberty Safeguarding Authorisation. Peggy died on the 11th November 2015 at Victoria House, Mill View Care Home, Bolton of asphyxia due to aspiration of pureed food, whilst being fed. The progression of the Alzheimer’s Disease, almost certainly caused her normal cough and epiglottis reflexes to no longer function, as explained by the Pathologist, which led to the asphyxia.

During the Inquest evidence was heard that:-

1. A Care Assistant giving evidence at the Inquest could not recall having been trained in the mechanisms of and techniques of how to feed a patient. Particularly there was no evidence of any training relating to the risks involved in feeding patients nor as to the risks created by particular conditions from which patients were suffering.

2. There was no evidence of there being any refresher training in the above matters.

3. There was no evidence of there being any training available to family members and others close to patients in the above matters. There was clear and striking evidence that family members and others would appreciate such training being available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones. There was also evidence that being able to do this in a professional and safe manner would be a great comfort to patient’s relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient.