William Joseph WILSON · Prevention of Future Deaths report

On 13/02/2017 I commenced an investigation into the death of William Joseph WILSON. The investigation concluded at the end of the inquest 8th June 2017. The conclusion of the inquest was Mr Wilson was enjoying a meal at the Church Inn, ████████ on the 26th November 2016 when he suddenly choked as a result of a piece of steak becoming lodged in his throat. He was asphyxiated and suffered a fatal hypoxic brain injury and died at The Meadows, Stepping Hill Hospital on the 2nd February 2017.
Hypoxic Brain Damage
Choking

Hypertension

Date Admitted: 26/01/2017

Consultant responsible for patient at time of death: ████████
Patient brought in by ambulance to the emergency department on the 26/1/2017 at 14:58 following a choking on a large piece of steak. Attended by paramedics within 4 minutes of choking and was resuscitated following which he expelled a large piece of steak. Unfortunately, he sustained hypoxic brain damage and was in coma as a result and following intensive care review it was considered that this was a terminal event and he was transferred to medical ward for end of life care. He was treated for aspiration pneumonia but deteriorated further with no improvement in his conscious levels. Following discussion with his daughter it was considered that palliative care would be provided in Bluebell ward where he died on the 2/2/2017.
Relevant PMH Hypertension

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene.
(2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene.
(3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson.