Norman Barnes · Prevention of Future Deaths report

On 22nd November 2021 I commenced an investigation into the death of Norman Barnes who died, aged 67, on 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent.

The investigation concluded at the end of an inquest on 10th February 2022, conducted by me. I gave a narrative conclusion that:
Norman Barnes died on the 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent. He had choked on food whilst eating his lunch in the lounge of the care home. His lunch was not minced or moist as per the recommendation of his SALT assessment and devised care plan. This occurred on a background of Parkinson’s disease which affected his swallow.

The medical cause of death was:

Ia. Inhalation of Food
Ib.
1c

II. Parkinson’s Disease

Norman Barnes died on the 17th November 2021 at Ashley Gardens Care Centre, 419 Sutton Road, Maidstone, Kent. He had choked on food whilst eating his lunch in the lounge of the care home. His lunch was not minced or moist as per the recommendation of his SALT assessment and devised care plan. This occurred on a background of Parkinson’s disease which affected his swallow.

Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that:

(1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident.

(2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents.