Norman Dorn · Prevention of Future Deaths report

Mr Norman Henry Charles Dorn died on the 26th August 2014. An investigation was opened on the 2nd September 2014 and was concluded by way of an inquest on the 3rd March 2015. The causes of death were 1(a) Asphyxiation 1(b) Complete Obstruction Of Trachea By Food Particles and in part II Gastric Mucosal Tear With Severe Bleeding. An open verdict was returned.

Norman Dorn was found and was presumed to be dead in an armchair at Porte Rouge Residential Home, Vicarage Road, Torpoint at around 11:30 on 26th August 2014 with a sandwich in his hand and with excess food in his mouth. He was last seen alive 10 to 15 minutes before eating a jam sandwich and drinking apple juice. He was known to have swallowing problems and had been provided with soft food. There were no staff trained to recognise death and they did not make attempts to remove the food from his mouth or resuscitate him as required by the care home policy. Nor did the GP attend in a timely manner when requested or staff from other emergency services.

It was not clear whether such actions could have resuscitated him or not.

1. That some care homes in Cornwall may not have adequate policies in place for their residence to appropriately recognise or arrange confirmation of death (i.e. when to call Emergency Service and or GP to recognise death). If such policies are in place that they are regularly updated and the staff are made aware of them and given the appropriate training.

2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate). If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training.