Helen Ruth BURNELL · Prevention of Future Deaths report

On 18th July 2019 I commenced an investigation into the death of Helen Ruth BURNELL, 60 years. The investigation concluded at the end of the inquest on 23rd March 2022. The conclusion of the inquest was; On 13th July 2019 at Blackdown House, Somerset Court, Harp Road, Brent Knoll Helen Burnell, who was diagnosed with Autism, was served a sandwich for dinner which had been cut in half and which was not cut up in accordance with professional advice given that only food that had been cut up in to bite sized pieces approximately 1.5 cms by 1.5 cms should be offered. Helen Burnell, under supervision at the time of eating her dinner, choked on the sandwich and suffered a fatal hypoxic brain injury. Helen Burnell had at the time of her death undergone a number of changes to her haloperidol prescription against a backdrop of having an unusual form of hypersensitivity to haloperidol withdrawal.

Choked whilst eating her dinner followed by respiratory then cardiac arrest. Approximately 1 hour 20 minutes downtime before return of spontaneous circulation. Intubated in resus and transferred to intensive care unit. Started on antibiotics to cover aspiration pneumonia. Failed to demonstrate any neurological improvement over the following days and an EEG showed no seizure activity but diffuse brain injury. Was referred for organ donation with consent of family for liver and tissues but recipient could not be found in time. Ms Burnell died 16th July 2019 at 07:09.

1) I identified that better training should be given to staff in respect of choking risks. Choking is a serious health and safety risk and concern for adults with autism and those with learning disabilities. The risk of choking does not appear to have been adequately recognised by staff.
(2) Improved training of staff, care givers and their respective managers may have the potential to increase adherence to meal time recommendations and lessen the risk of choking.