Margaret Russell · Prevention of Future Deaths report

On 5 November 2021 I commenced an investigation into the death of Margaret Russell born on 26 October 1938. The investigation concluded at the end of the inquest on 27 October 2022. The conclusion of the inquest was:-

Margaret Russell was admitted to hospital on 31 October 2021 following a fall at home. This resulted in a fractured hip. She required surgery for that fracture. As part of the booking in process it was apparent that Margaret may have difficulties with swallowing and eating and a speech and language therapy referral was requested. This was subsequently missed by the ward and a referral was not made; further there were no mitigating temporary measures taken to manage Margaret's diet. Margaret was provided with a meal following her surgery on 1 November 2021. She choked on that meal. Initial measures were taken to remove the blockage however CPR was not commenced due to a DNA CPR in place. The failure to provide CPR was contrary to Trust and Resuscitation Council policy. She died at Barnsley Hospital on 1 November 2021.

The medical cause of death was:

1a: Respiratory Arrest
1b: Aspiration
2: Ischaemic heart disease, diabetes mellitus

On 31 October 2021 Margaret Russell was admitted to Barnsley District General Hospital following a fall at home. She suffered a fractured hip as a result of the fall and required surgery for this. During her booking in process staff were made aware that Margaret may have difficulties with swallowing, and this was noted on her records. Unfortunately, this was missed by ward staff and following her procedure she was provided with a meal which she choked on.

Emergency services were instigated however the medic attending noted the DNR in place for Margaret and did not commence CPR. This was a breach of the Trust and Resuscitation Council Policy and may have led to a different outcome for Margaret.

1. The decision not to commence CPR in these circumstances was not in accordance with Trust or National Policy and in some cases may make a significant difference to outcome.