Keith Barton · Prevention of Future Deaths report

On the 3rd December 2013 I commenced an investigation into the death of Keith Barton, 77 years. The investigation concluded at the end of the inquest on the 4th December 2013. The conclusion of the inquest was that Keith Barton died as the result of an accident, the medical cause of death being 1a. Inhalation of food II Dementia. Box 3 was completed that Keith Barton suffered from Alzheimer's disease and dementia. He had a history of pocketing food and not swallowing and was therefore at a risk of choking. He was assessed by a speech and language therapist as requiring supervision and monitoring whilst eating. At the nursing home supervision was by way of periodic check. On the morning of the 5th February 2013 he choked and died whilst eating his breakfast in his room on his own. There is no evidence that he was checked while eating his breakfast

Keith Barton had a history of Alzheimers disease and dementia and as a result had a history of pocketing food and not swallowing. He was therefore at risk of choking. Whilst resident at Ashley Gardens nursing home he had been assessed by a speech and language therapist (SALT) as requiring supervision and monitoring while eating. It was not clear whether this was communicated at the time of the assessment but was confirmed in writing at a later date. This was interpreted by staff at the nursing home as intermittent rather than constant supervision when eating breakfast in his room he was subject to periodic checks. The majority of meals were taken in a communal area. There were 3 previous documented choking incidents prior to Mr. Barton's death, on each occasion staff were on hand to assist and no harm occurred. On the 5th February 2013 Keith Barton was eating breakfast in his room when he choked and died. There was no evidence that Mr. Barton had been checked whilst eating his breakfast by any of the staff on duty. The SALT gave evidence at the inquest that by supervision and monitoring she meant constant supervision by someone sitting with him or in close proximity. The nursing home did not ask for clarification of the recommendations communicated in the letter from the SALT which was somewhat ambiguous.

(1) That clarification as to the level of supervision and monitoring was not sought from the speech and language therapist in a case where the recommendation required clarification
(2) That external training in relation to dysphagia awareness which had been put in place following the death of Mr. Barton could not be delivered to all staff members because of constraints on the number of places available (which could potentially be resolved by in-house training)
(3) That incident reports were not completed and therefore a further SALT review had not been triggered (this has been addressed by the nursing home and does not require further action to be taken)
(4) That residents at risk of choking were subject to periodic checks (this has been addressed by the nursing home and does not require further action to be taken)