Jacqueline Aarons · Prevention of Future Deaths report

On the 21 November 2024 commenced an investigation into the death of, Jacqueline Aarons, aged 60. The investigation concluded at the end of the inquest on 29 October2025. The conclusion of the inquest was Consequences of an unrecognised but symptomatic umbilical hernia.. The medical cause of death was 1a Aspiration, 1b Strangulated umbilical hernia, 1c Downs Syndrome.

On the 19ᵗʰ November 2024 Jacqueline Aarons died at her Care Home from the consequences of a strangulated umbilical hernia.

Miss Aaron had become unwell with symptoms of vomiting after breakfast on the 17ᵗʰ November 2024.

The staff, none of whom were medically trained, called 111 and an Out of Hours doctor called the care home, felt that the patient had gastroenteritis and gave advice for better management of the patient. The Care Home doctor spoke to the staff the next morning and arranged for a Rapid Response nurse who attended and was reassured that Miss Aarons appeared to be settling. The nurse spoke to a doctor at the surgery before providing written advice to the staff when they may need to contact 999

Miss Aarons become more unwell, and an ambulance was called and attended on the morning of the 19ᵗʰ November 2024.

The cause of the vomiting after breakfast on the 17ᵗʰ November 2024 is likely to be a partial obstruction related to the hernia which is likely during the early hours of the 19ᵗʰ November 2024 to have progressed to a complete obstruction leading to aspiration of stomach contents.

Had Miss Aaron been admitted to hospital at any point from when the vomiting started to the point at which she collapsed and stopped breathing at the Care Home it is likely that she would have survived.

Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability

There should be a fact to face consultation by a doctor.

Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained.