Geraldine Butterfield · Prevention of Future Deaths report

The inquest into the death of Mrs Butterfield was opened on the 5 August 2015 and was resumed and concluded on the 24th January 2017.
The cause of death was:
1a – Asphyxia due to food inhalation.
The inquest concluded with a narrative conclusion.

Mrs Butterfield was a resident at Collingwood Grange nursing home in Camberley. The nursing home is run by BUPA Care Services Limited and Mrs Butterfield’s placement was funded by Surrey County Council.

On 25 July 2015 Mrs Butterfield was eating her lunch in the dining room when she was noticed to be slumped over in her wheelchair. A nurse attended and checked Mrs Butterfield’s mouth and did not see any food, she positioned her so as to maintain her airway and slapped her on the back. She then arranged for Mrs Butterfield to be wheeled to her bedroom where she was placed in the recovery position on her bed. Another nurse then repeatedly slapped Mrs Butterfield on the back and used a suction machine to remove food from her mouth and the opening of her throat. The court heard evidence that the suction machine was not capable of removing food from Mrs Butterfield’s airway. Mrs Butterfield was then placed on the floor in preparation for carrying out Cardio-Pulmonary Resuscitation (CPR). However, CPR was not ultimately attempted because Mrs Butterfield had a valid Do Not Attempt to Resuscitate (DNAR) order in place, and her death was confirmed by attending paramedics at 13:09. The court heard evidence that repeated back blows were not attempted until Mrs Butterfield had been transferred to her room and placed on the bed and that no attempt was made to carry out any abdominal thrusts, in contravention of the BUPA policy on choking.

Having heard evidence from a number of members of the nursing staff, I am concerned that not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking, so as to be able to effectively implement it in the future. I am also concerned that not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place.

- Not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking so as to be able to effectively implement it in the future.
- Not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place.

Consideration should be given to whether any steps, including further training, can be taken to address the above concerns.