Margaret Bailey · Prevention of Future Deaths report

On 31.01.24 an investigation commenced into the death of Margaret Bailey who died on 17.12.23 at her home address. Margaret was aged 73 years, having been born on 12.01.49.

Interested Persons
Margaret Bailey’s
Right at Home
Stepping Hill Hospital
Stockport MBC

The inquest concluded on 18.06.25.

The medical cause of death was
1a) Aspiration of Gastric Contents
1b) Episode of vomiting
1c)
1d)
2 Multiple Sclerosis

How, when and where
Margaret Bailey died at her home on 17 December 2023 having been sick while resting/sleeping in her bed giving rise to an extensive aspiration of the stomach contents. Margaret Bailey was diagnosed with multiple sclerosis in her early 30’s and at the time of her death was bed-bound and wholly dependent for all personal care. Although MB suffered with mild dysphagia she did not have a history of reflux or vomiting, and the cause of her vomiting is not known.

Conclusion
Narrative: Died as a consequence of a reduced gag reflex and ability to protect the airway; a recognised symptom of multiple sclerosis.

At the time of her death Margaret Bailey lived at her own home, with a care package provided by Right at Home – a provider of domiciliary care – commissioned by Stockport MBC. Margaret had a 24hr Live-in carer, supported by Pop-in carers (4 x 30 mins per day) and a Carer carer for 2hrs per day. Direct care was averaged at 12hrs per day.

On the morning of 17.12.23, when the 1st Pop-in carer attended to assist the Live-in Carer to get Margaret up, it was noted that Margaret had suffered a episode of diarrhoea. Margaret was cleaned and changed. No other concerns were noted. The 2nd Pop-in carer arrived at about 11.20hrs. This carer felt that Margaret looked unwell and contacted Right at Home office to report this, as per policy. The office note states that the carer was advised “we will monitor and get in touch with gp tomorrow if still under the weather”.
The Cover-carer attended at about 13.13hrs (2hrs). The Cover-carer had read the notes and was aware of the earlier call to the office re Margaret but had not received any information as to ‘monitoring’ her. This carer noted that Margaret was hot and sweaty, with cold hands and feet. Margaret was sat out in her chair. Margaret’s daughter happened to visit at the same time. There was conflicting evidence as to whether a thermometer was available in the home. The carer said not. The daughter said there was. The carers evidence was that had an thermometer been available she would have taken Margaret’s temperature. In any event no temperature was taken. The Cover carer left at about 15.00hrs.
At some time between 16.00hrs and 16.30hrs when the 3rd Pop-in carer arrived Margaret was assisted back into her bed for a rest, being positioned, as per usual, semi-prone. She was still looking unwell. The Live-in carer retired to her room to allow Margaret peace.
Some time after 18.00hrs and before 18.35hrs the Live-in carer returned to Margaret’s room to discover that she had been sick and was unresponsive. CPR was commenced. Paramedics attended but Margaret was clearly deceased. Death confirmed at 18.41hrs.

Post-mortem examination evidence was that the extent of aspiration was so great that even in a hospital setting it is unlikely that resuscitation would have been successful.

1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the ‘office’.

2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.