ASHLEY ERNEST NOTSON · Prevention of Future Deaths report

At the conclusion of the inquest into the very sad death of ASHLEY ERNEST NOTSON, I recorded a conclusion of ‘Accidental death’. The cause of death was found to be: 1a Hypoxic brain injury due to 1b Hypoxic cardiac arrest due to 1c Upper airway obstruction from inhalation of a foreign body, with Autistic spectrum disorder in Part II.

Ashley Notson died in very tragic circumstances at the age of 55 after a period of time in hospital where he was taken after choking on a piece of meat at the care home in which he lived. Attempts to resuscitate him, including Heimlich manoeuvres, were conducted by a staff member on duty at the care home who had previously had training in first aid but, sadly, Mr Notson passed away from hypoxic brain injury resulting from the choking episode.

The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training. Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present.

The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after, but that this was not a legal requirement either.