Joyce Crompton · Prevention of Future Deaths report

On the 28th January 2016 I commenced an investigation into the death of Joyce Crompton, born on the 20th March 1936.

The investigation concluded at the end of the Jury Inquest on the 2nd December 2016.

The Medical Cause of Death was:

Ia Airway Obstruction
Ib Regurgitated food in the mouth and pharynx

II Vascular Dementia

The conclusion at the Inquest was Choking on regurgitated food, with the underlying cause of Vascular Dementia.

On the 26th January 2016 Joyce Crompton was found in an unresponsive condition in the bathroom of her room at her place of residence at Belong Village, 55 Mealhouse Lane, Atherton. She had been eating her evening meal prior to this in the dining area. She got up from the table and was later found in her room with food in her mouth and food on the floor beside her. Prior to her death she had been witnessed to have two incidents of choking. One on the 14th September 2015 and one on the 10th December 2015. On the latter occasion the paramedics and out of hours GP had attended. The GP had advised that she should be referred to the Speech and Language Therapy (SALT) Team for assessment of her swallowing. This was not done. At the time of her death Joyce was the subject of a Deprivation of Liberty Safeguarding Authorisation.

1. During the inquest evidence was heard that:

i. When a resident at Belong Village chokes there should always be a referral to the SALT team to assess their swallowing. A fax is sent by the home to the GP who then will submit a referral to the SALT team. Once the fax has been sent to the home the staff will chase up the referral by telephone. If a referral is done it will be recorded in the GP healthcare visits section of the resident’s notes.

ii. There is no written policy or procedure in place and staff are given verbal advice on referrals to outside agencies, such as SALT, when they start working at the home. There is no systematic checklist to complete to ensure a referral has been done or to confirm when the referral has been chased.

iii. After the witnessed choking incident Mrs Crompton experienced at Belong Village on the 14th September 2015 a referral was not sent to the GP or to SALT.

iv. After the witnessed choking incident Mrs Crompton experienced on the 10th December 2015 at Belong Village, a referral was not made to the GP or to SALT. It was recorded in the notes and the home diary that a referral to SALT was to be done, but none of the staff did the referral. The staff who gave evidence at the Inquest all confirmed that they had presumed that it had been done, however there was no record on the GP Healthcare visits sheet that a referral had been done.

I have concerns with regard to the following:

i. It is clear that although there is verbal training given on referrals to outside agencies, such as SALT, there is no written guidance that can be easily referred to when incidents arise. There is also no refresher training on the policies. Due to this there may be another occasion in the future when a referral to the SALT team is missed which could result in a future death.

ii. I therefore request that a review is undertaken of the policies, procedures and training in place at Belong Village in relation to referrals to the SALT team to avoid future referrals being missed.