Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report

On 6 September 2024 I commenced an investigation into the death of Neville Daniel Elisha MCKENZIE. The investigation concluded at the end of the inquest. The conclusion of the inquest was that death was due to accidental choking as a consequence of cognitive impairment.

Mr McKenzie died at City Hospital, Birmingham on the 25th August 2024 as a result of the effects of a cardiac arrest caused by an incident of choking on the 13th August 2024 at his care home. Mr McKenzie was recognised to be at risk of choking because his dementia meant he would eat quickly and put too much food in his mouth. Consequently, his care plan was for him to be supervised eating and encouraged to sit and eat slowly. On this occasion he had eaten his lunch under the general supervision of staff and left the dining room without giving any cause for concern. A short time later he was witnessed to be choking by staff who immediately commenced manoeuvres to try and remove the food from his airway but this was unsuccessful and he went into cardiac arrest. He received CPR and was successfully resuscitated by paramedics and transferred to hospital but had suffered an un-survivable brain injury.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:

1a Hypoxic brain injury

1b Cardio respiratory arrest

1c Choking

1d

II Dementia

1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths.
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced.