Susan Paley · Prevention of Future Deaths report

On 18th October 2024, I opened an inquest into the death of Susan Paley who died on 11th May 2024 at Hilltop Court Nursing Home, Lodge Hill, Stockport, aged 65 years. The investigation concluded with the inquest which I heard on 22nd November 2024.

A post mortem examination determined Ms Paley died as a consequence of:

1) a) Asphyxia;

1) b) Food bolus obstruction.

At the end of the inquest, I recorded a conclusion of Accident.

Ms Paley was a resident at Hilltop Court Nursing Home who was significantly dependent on the care of others as a consequence of complex neurological problems which left her with tremors, contractures and very limited mobility. Whilst Ms Paley had previously reported swallowing problems, the outcome of her most recent Speech and Language Therapy Assessment was normal meaning no modification was required to her diet.

On 11th May 2024, a Healthcare Assistant had left Ms Paley with a sandwich to eat in bed in her room. When around an hour later the same staff member returned to check on Ms Paley, she found her unresponsive. Whilst staff sought to assist Ms Paley and an ambulance was called, an attending paramedic confirmed she had died.

Ms Paley died having choked on food whilst eating in her bed.

1. Given Ms Paley’s significant health problems and very limited mobility, it is a matter of concern that she had been left in bed without a call bell to hand which she could easily reach should she need to summon assistance; and

2. I am concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call-bell, sensor-mats etc.) have them in place as indicated.