Irene Collins · Prevention of Future Deaths report

On 7th November 2018, an inquest was opened into the death of Irene Collins who died on 16th June 2018 at Firbank House Residential Home, Ashton-under-Lyne aged 78 years. The investigation concluded with an inquest which I heard between 22nd-24th July 2019 and which concluded with a Narrative Conclusion to the effect that Mrs Collins died as a consequence of obtaining and ingesting a latex glove whilst unsupervised at her care home.

Mrs Collins was formally diagnosed with dementia in 2015. Following the sudden death of her husband in 2017, she was assessed as requiring full-time residential care and after a brief period in another establishment, moved into Firbank House Residential Home.

By this time Mrs Collins’ health problems had become complex and significant and included Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, low mood, Ischaemic Heart Disease, Chronic Kidney Disease stage 3 and macular degeneration, in addition to dementia.

Over the final months of Mrs Collins’ life, her dementia became advanced and she developed an appreciable propensity to insert foreign objects into her mouth.

On 16th June 2018, Mrs Collins was found dead in a chair in the communal lounge of the care home. At post mortem examination, a pathologist acting on behalf of the coroner found a latex clinical examination glove in Mrs Collins’ proximal trachea / larynx.

The examination was stopped and a forensic post mortem examination then took place. The conclusion of the Home Office pathologist was that Mrs Collins died as a consequence of:-

1a) Upper airway obstruction;
2) Multi-infarct dementia.

The court heard evidence that at Firbank House, there was unrestricted access to clinical examination gloves and other personal protective equipment intended to be used by those delivering care from wall-mounted dispensers in corridors. Additionally, at that time, once used the clinical examination gloves could be disposed of in a variety of bins, which were again easily accessible to residents.

Whilst significant steps have now been undertaken at Firbank House to restrict the access of clinical examination gloves to residents with cognitive impairment, it is a matter of concern that in many settings where care is provided to vulnerable people, they are extremely easy to access.

It is considered an alert or authoritative guidance as to the storage and disposal of clinical examination gloves in care settings may prevent future deaths.