Mr Kenneth Clarke · Prevention of Future Deaths report

On the 3rd August 2017, I commenced an investigation into the death of Mr Kenneth Clarke. The investigation concluded at the end of the inquest on 25 February 2020. The conclusion of the inquest was narrative contributed to by neglect of the Nursing Home Mr Kenneth Clarke was resident in.

The cause of death was:

1a Inhalation of food material,

i) Mr Clarke was a 74 year old gentleman who was resident in Normanton Village View Nursing Home. His past medical history included strokes, which had left him with issue swallowing, and thus a high risk of choking. He also suffered with dementia. He was on a puree only food diet but his dementia meant he did not appreciate this and would often wander round the home in search of food.

ii) Mr Clarke had been risk assessed by the home and to reduce his risk of choking, measures were put in place. Firstly, he was on a puree food diet. Secondly, he had a pressure sensor mat to the side of his bed to alert staff when he left his room. Thirdly, staff were to be stationed at observation points around to observe if patients left their rooms. Fourthly, the kitchen, where food could be accessed, was to be locked and had a pin operated lock was in place. Finally, food was to be kept in cupboards in the kitchen or in the fridge.

iii) On the 23rd July 2017 Mr Clarke left his room. The pressure sensor mat did not activate. It is not clear whether this was because it was not working. Whether it was in the correct place, or whether Mr Clarke moved it himself. The staff at the home were not at the designated observation points and did not see him leave his room. He made his way to the kitchen, which was unlocked. He ate a piece of bread that had been left out and not put away in a cupboard or fridge. He choked and died.

1. Evidence emerged during the inquest that Normanton Village View Nursing Home had no formal policies covering how residents were to be observed, how foods were to be stored, locks on the kitchen and cupboards, dementia residents or residents on a liquid food diet.