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Investigation and inquest
On 3 December 2024, I commenced an investigation into the death of Mrs Rashida Sultana born on the 24 April 1948 who died on the 20 November 2024. The investigation concluded at the end of the inquest on 1 October 2025.
The inquest was heard before myself sitting without a Jury and my conclusion at inquest was the deceased died after choking on chips and some water she was eating and drinking.
The medical cause of Mrs Sultana’s death was recorded as
1a Asphyxia
1b Choking on Food
II Dementia, Heart Failure, End Stage Renal Disease, Ischaemic Heart Disease
Circumstances of the death
1. Mrs Sultana was admitted to Midland Metropolitan Hospital after presenting with symptoms of right facial drooping and slurred speech on the 18 November 2024.
2. A CT head scan confirmed she had no acute stroke but did have evidence of brain atrophy and moderate to severe small vessel disease. She also had a history of dementia, chronic kidney disease and additional comorbidities. A Do not attempt to resuscitate (DNAR) order was put into place by the Clinicians.
3. During her admission, it wasn't deemed a Speech and language therapy assessment (SALT) was required despite her risk of dysphagia from dementia and evidence of dribbling from her mouth
4. On the 20 November she choked on some chips and water the family had brought in to feed her. The nurse on duty described performing life support- administrating 5 blows to her back and using suctioning. He then contacted the on-call Doctor.
5. The on-call Doctor confirmed he wasn’t told she was choking and was dealing with another emergency at the time. He was told that Mrs Sultana was struggling to breath and that he would attend as soon as he could. There was no mention of the patient becoming unresponsive.
6. The nurse then contacted the Emergency Medical Response Team (EMRT) and when they arrived, she sadly had already passed away and nothing further could be done.
Coroner’s concerns
1. During the course of the inquest, I heard evidence Mrs Sultana was approaching end of her life and had a DNAR in place due to her multiple comorbidities.
2. My concern is that there was confusion and lack of understanding by nursing staff in relation to when the EMRT should be called in an emergency particularly when a DNAR was place.
3. In addition, there was a lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place.
Information checked against the published report and official responses