Ronald James JEPSON · Prevention of Future Deaths report

On 16th March 2023 I commenced an investigation into the death of Mr Ronald James JEPSON (aged 75 years). The investigation concluded at the end of the inquest on 19th January 2024 at Coventry Coroners Court. The conclusion of the death of Mr Jepson was that death was “misadventure”, a copy of which I attach to this report.

Ronald James JEPSON had a history of schizophrenia, and resided at Meadow House, a mental healthcare facility. An aspect of Mr Jepson’s care plan was supervision when he was provided a meal/eating, Mr Jepson with a known risk of cramming food into his mouth and thereby choking. On 14th March 2023 Mr Jepson was sat in the TV lounge and provided his supper which consisted of some jam sandwiches. It was inconclusive as to whether the jam sandwiches were cut into sufficiently small pieces. Also in the lounge was another resident with the same meal. Mr Jepson, a short time later, his plate cleared from the room, had an unwitnessed choking episode. Care home staff, upon hearing Mr Jepson 'gargling', came to his location in this emergency situation. 111 was called by care home staff, in due course the matter correctly escalated by the call handler to enable an ambulance to be immediately dispatched. First attempts as resuscitation by care staff were following an appreciable period of time and the cardiopulmonary resuscitation was sub optimal. Ronal Jepson had turned blue (cyanosis) and an ambulance arrived. Despite paramedics attempts at resuscitation at Meadow House care home (a return of spontaneous circulation attained) and at UHCW hospital, Mr Jepson did at hospital on 15th March 2023, the cardiac arrest precipitated by the episode of choking on food, (food lodged in the windpipe and thus air prevented from getting to the lungs thereby damaging vital organs and causing the deceased heart to stop).

i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff.
ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999.
iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal.
iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis.
v. A choking episode, of itself, is a time critical event.
vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal.
vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance.