John Fallon · Prevention of Future Deaths report

On 16th March 2022 I commenced an investigation into the death of John Fallon. The investigation concluded on the 7th September 2022 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Choking on food; 2) Dementia

John Fallon had dementia and was resident at Downshaw Lodge Care Home. On 13th March 2022 he was eating his lunch without his dentures in. He had cut up his own food. He began to choke. Emergency services attended and a large piece of partially chewed meat was retrieved using suction on his airway. He was transferred to Tameside General Hospital where resuscitation attempts were continued. They were unsuccessful. He died at Tameside General Hospital on 13th March 2022.

1. The inquest heard evidence that although he needed his dentures to chew in a satisfactory way, SALT assessments are not routinely carried out where an individual goes from eating with dentures to eating without dentures. As a consequence the diet is not routinely altered in a care home setting to reflect the reduced chewing capacity;
2. Evidence was also heard that the limited availability of dental services to care home residents means that situations where dentures require updating/replacing are not being dealt with promptly which means there is a greater risk of choking on food that has not been adequately chewed;
3. NWAS used a suction machine to clear the airway on their arrival. The inquest heard evidence that these are not routinely in place at care homes and so if a resident is choking food cannot be suctioned out by staff.