Craig Brendon SPIBY · Prevention of Future Deaths report

On 30 July 2024 I commenced an investigation into the death of Craig Brendon SPIBY aged 49. The investigation concluded at the end of the inquest on 21 November 2024. The conclusion of the inquest was that:

Accident contributed by neglect.

The deceased suffered from Phelan McDermid Syndrome - a rare and debilitating chromosomal disorder, that amongst other symptoms, rendered him susceptible to choking on food and liquids at mealtimes. From 2009, the deceased’s extensive health care needs were being met actively upon him becoming a full time resident at a locally authority funded assisted living facility at ████████ in ████████ Farmworth. On the 13th of July 2024, when eating his lunch whilst unsupervised and only indirectly monitored in the kitchen of the residence, he rapidly became collapsed and unresponsive having inadvertently choked on a sandwich. His condition was not appreciated for a significant period, the duty carer on returning to the kitchen erroneously assumed the deceased had fallen asleep until later realising the deceased was totally unresponsive. Despite prompt attendance and attempted resuscitation by emergency paramedics, he failed to respond and at 12.23pm that day was pronounced dead. A post-mortem established the deceased to have choked on a bolus of masticated sandwich that had lodged in his windpipe that would have caused hypoxic driven cerebral malfunction and potential loss of consciousness within four minutes and irreversible cardio-respiratory failure within 10 minutes.

The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.