Barbara Haley · Prevention of Future Deaths report

On the 23rd October 2017 an inquest was opened into the death of Barbara Haley. The inquest took place on the 29th March 2018 and the conclusion was one of Natural Causes. The medical cause of death was:

1a Aspiration Pneumonia
1b Alzheimer's Dementia

On the 13th October 2017 or in the days prior, Mrs Haley had inhaled either vomit, saliva, food or liquid whilst resident at Hilltop Court Care Home. This led to the development of a chest infection and her condition deteriorated suddenly on the morning of the 13th October 2017. An ambulance was called and she was transported to Stepping Hill Hospital but suffered a cardiac arrest en route and passed away at Stepping Hill Hospital on the morning of the 13th October 2017.

Whilst these matters did not contribute to Barbara Haley's death, they did reveal matters giving cause for concern in respect of the risk of future deaths:

1. Mrs Haley was on a soft diet (described as a “fork-mashable diet” in evidence). Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff. In particular, on one occasion toast was found in her room. On another occasion, staff had apparently suggested to a family member that chocolate could be given to Mrs Haley.

2. During the course of her evidence, ████████ (Home Manager) explained that Mrs Haley was assessed as being at High Risk of choking and scored high on the risk assessment that had been carried out. Despite this, Mrs Haley would be left alone in her room to eat because ████████ stated she did not like to have staff present when she was eating; she would then refuse to eat. We heard evidence from a manager at another home that Mrs Haley would eat when she was in the dining room with other residents, where staff could also observe her. It was of concern that Mrs Haley was being left alone in her room to eat when she had been assessed as being at the high risk of choking.