Tina Jane Allen · Prevention of Future Deaths report

On 15 June 2022 I commenced an investigation into the death of Tina Jane Allen. The investigation concluded at the end of the inquest on 5 December 2022. The conclusion of the inquest was as follows

The medical cause of death

1a Aspiration Pneumonia
1b Choking
II Neurological Condition Autism

The answers to the statutory questions - who, when, where and how – were answered as follows …

Tina Jane ALLEN died on 15 June 2022 at Royal Cornwall Hospital Treliske Truro Cornwall from choking on high-risk food against a background of autism being a known risk for choking

My narrative conclusion as to the death was

Choking contributed to by neglect.

Tina was diagnosed with severe autism requiring 24-hour care on a 1:1 basis. Tina lived at Valley View House in Cornwall. Valley View is a Registered Care Home, which is owned and managed by HFT.

Tina had eating and drinking guidance in place, assessed by a Speech and Language Therapist (SALT) requiring a diet of soft and mashed food and avoiding high risk foods.

Tina choked on food given her by carers on 13 June 2022 and was admitted to hospital. She died two days later. On the basis of evidence from the SALT the court found that the foods given on 13 June were high risk could not have been prepared safely. It was found that Tina was fed high risk foods for at least 3 months by carers at the home. There was evidence staff were unaware of the extent of the eating plan.

The management at the care home had not completed routine checks which would have revealed this error. There was a requirement for extra vigilance by management following a choking incident in 2020 in which Tina had required CPR and was airlifted to hospital for treatment.

On the day of the fatal incident the care home was at least one third understaffed. Staff report ongoing issues of understaffing that impact on the ability to safely provide care and training. Staff have alerted management to these staffing issues on a number of occasions.

The court heard that on a majority of days the care home is understaffed.

That the persistent understaffing at the care home is impacting upon the ability of staff to safely provide the care and treatment required. Further, the understaffing is impacting upon the ability of the care home management to properly monitor the safety and appropriateness of the care given at the care home.

The care home is invited to review the staffing levels at the home and the relevant recruitment and retention policies and strategy.