Keith Ineson · Prevention of Future Deaths report

On 30 April 2025 and 23 May 2025, at an inquest held at Blackpool Town Hall, I returned a narrative conclusion that Mr Keith Ineson died following a following a choking episode at Blackpool Victoria Hospital, where he was being treated following a fall at the Glenroyd Care Home.

I found the cause of death to be:

1(a) Respiratory failure 1(b) Aspiration pneumonia 1(c) Choking episode II Fractured neck of femur (operated on 28.4.24) Coronary artery atherosclerosis.

I returned the following in box 4 of the Record of Inquest recorded:

Mr Keith Ineson resided at the Glenroyd Care Home, 164 Whitegate Drive, Blackpool, FY3 9HF. It was known that Mr Ineson was at risk of suffering from falls and required an altered diet. On 26 April 2024, Mr Ineson was in the process of mobilising when he suffered an unwitnessed fall. The carer in attendance had left the room and upon their return, Mr Ineson was found on the floor.

On 27 April 2024, Mr Ineson was taken to Blackpool Victoria Hospital where he underwent a right hemiarthroplasty. On 3 May 2024, and following the right hip hemiarthroplasty surgery, Mr Ineson suffered a choking episode on food. Mr Ineson developed aspiration pneumonia and, despite treatment, Mr Ineson’s condition deteriorated and he died on 6 May 2024 at Blackpool Victoria Hospital.

Mr Keith Ineson was a resident at the Glenroyd Care Home from 6 June 2019. It was known to the Glenroyd Care Home that Mr Ineson was a high falls risk, and measures had been put in place to address this issue.

Following the fall on 26 April 2024, I found that the senior carer who checked Mr Ineson for signs of injury had conducted an inappropriate assessment.

It was noted in the evidence, that the observation scores taken for Mr Ineson following his fall had not all been recorded in Mr Ineson’s care notes. This left a gap in the evidence as to reviewing the need for escalation to medical services after the fall.

I received from witnesses who gave evidence before me, helpful assistance concerning several issues about learning and changes that had been made following Mr Ineson’s death.

I could not identify changes to the record keeping system though, and as such found that the issue around the absence of recording observation scores following a fall gave rise to a risk of further death. This was because the record keeping was inaccurate, contained gaps in the information, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.