Jonathan Brett Yates · Prevention of Future Deaths report

On the 10th April 2018 I commenced an investigation into the death of Jonathan Brett Yates. The investigation concluded at the end of the inquest on the 2nd April 2019. The conclusion of the inquest was a hybrid conclusion of accidental death and a narrative conclusion. The medical cause of death was 1A The effects of aspiration of gastric contents 1B Oropharyngeal stenosis due to treated oropharyngeal carcinoma with PEG feeding hepatic steatosis.

Jonathan Brett Yates was a 68 year old who lived alone .He had a significant medical history including alcohol dependency, ischaemic heart disease, previous transient ischaemic attack, treatment for squamous cell carcinoma and ongoing swallowing difficulties. He had been fitted with a PEG feeding tube in 2016. On the 17th March 2018 he suffered a fall outside his home which was believed to be alcohol related, and he was admitted to hospital for further investigations. CT imaging ruled out any head injury. On the 19th March 2018 his PEG was fixed and he was referred to a dietician. At approximately 18.30 hours an evening meal was delivered to Mr Yates. He should not have received this meal as he was nil by mouth. Mr Yates was aware of this fact. Mr Yates attempted to eat the food, he choked and food passed into his breathing tube causing him to stop breathing. He suffered a cardiac arrest. Resuscitation attempts resulted in his heart being restarted. However due to his prognosis, further active treatment was not pursued. Palliative care was commenced and Mr Yates passed away at 14.45 hours on the 20th March 2018.

How the nutritional status of a patient, in particular when a patient is nil by mouth, is communicated effectively to staff caring for a patient during an admission to hospital.