Peter Scott · Prevention of Future Deaths report

On 16th of October 2014 I commenced an investigation into the death of Peter Scott Furness then aged sixty six. The investigation concluded at the end of the inquest on the 30th of September 2015. The conclusion of the inquest was Accidental Death, the medical cause of death being 1(a) Choking on a Latex Glove (b) Dementia.

1. The Deceased, who had been diagnosed with Frontal Lobe Dementia, was a resident at the Nursing Home which provides care for persons with dementia.
2. He was known to be at risk of placing non-edible items in his mouth and had been observed doing so on a number of occasions.
3. Although risk assessments had been undertaken he collapsed on the 13th of October 2014 and was verified dead at the home at 12.32 hours.
4. A Post Mortem established that he had choked on a latex glove and two further gloves were found in his stomach which had been ingested previously.

The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated so as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care.