Henry Edward Hullin Doll · Prevention of Future Deaths report

An inquest into the death of Mr Doll was opened on 7 April 2021. The inquest was resumed on 18 October 2021 and concluded on 19 October 2021.

The medical cause of Mr Doll’s death was:

Ia. Aspiration Pneumonia
1b. Choking and Aspirating on a biscuit (21.2.21)

II Dysphasia, Learning, Disability, Dementia, Down’s Syndrome

The inquest concluded that Mr Doll’s death was due to an accident, contributed to by failures on the part of his residential care home.

Mr Doll had a Learning Disability, Down’s Syndrome and Dementia. He was non-verbal and did not have any insight into his own care needs. He lacked mental capacity and was subject to a Deprivation of Liberty Order. His care was funded by West Sussex County Council.

Mr Doll lived at Kenilworth, which is a residential care home for up to six people with autism or learning disabilities, which is owned and run by the Avenues Group. Residents at Kenilworth have free access to the kitchen.

Mr Doll had been assessed by the Speech and Language Therapy Team (SALT) as being at high risk of aspiration and choking. This was due to a number of factors, namely that he had dysphagia, in combination with a lack of teeth, and the fact that he did not chew his food before swallowing it. Accordingly, the SALT team made a number of recommendations on 20 December 2019, which included that Mr Doll should avoid dry foods and must always be supervised whilst eating.

On 21 February 2021 Mr Doll entered the kitchen at Kenilworth alone and got a shortbread biscuit from the biscuit tin. He choked and aspirated on it, resulting in his death from Aspiration Pneumonia the following day on 22 February 2021 at East Surrey Hospital.

The court found that those managing Kenilworth had failed to identify the risk of Mr Doll obtaining unsuitable food items from the kitchen and eating them in an unsupervised manner and had also failed to put in place appropriate measures to prevent him from doing so.

1. Both the Kenilworth Home Manager and the Regional Director, responsible for some 50 homes, maintained at the inquest that Mr Doll’s risk assessment had been accurately completed and that the appropriate way to conduct a risk assessment was to first consider what mitigating measures were in place and then to go on to assess the likelihood of the risk occurring and the likely impact on the individual.

Accordingly, the Coroner is concerned that the risk screening in respect of other residents at Kenilworth, but also other Avenues Group locations, may have been completed in a similar manner.

The Avenues Group is invited to consider carrying out an audit of the current risk assessments in place and to ensure that all those involved in the auditing process have a clear understanding of the process.

The Avenues Group is also invited to consider whether further training is required in relation to the completion of the risk screening tool.

2. The court found that the CPR provided by staff to Mr Doll on 21 February 2021 prior to the arrival of the paramedics was ineffective, albeit this did not contribute to his death.

The Avenues Groups is invited to consider whether staff have received sufficient practical training so as to ensure that they are confident and capable of carrying out effective CPR.