Edna Smither · Prevention of Future Deaths report

On 1st May 2013 I commenced an investigation into the death of Edna Smither dob 17th May 1920. The investigation concluded on the 30th July 2014 and the conclusion was one of Misadventure. The medical cause of death was 1a Asphyxia 1b Choking on Food.

On the 25th April 2013 at Peel Moat Care Home in Stockport, the deceased was being fed her lunch consisting of sausage and mashed potato. She choked on the sausage and died later that day in Stepping Hill Hospital.

1. It transpired during the course of the hearing that only one (comparatively junior) member of staff present on the day of the incident and death, had a First Aid certificate which was ‘in date’. Whilst I recognise that there is no legal requirement for this, none the less I feel it would be very helpful for all staff to have up-to-date certification, so that they would know when to, and how to, carry out abdominal thrusts to dislodge food boluses etc.
2. There was a door which Mrs Smither was to be carried through by the ambulance staff, and this door was locked. A delay occurred whilst this was unlocked. Was this door in fact a fire escape door, and if so has the situation now been changed?
3. All the staff in attendance, by their own admission, were in a state of panic. No-one, including the senior staff took a position of calm leadership and there seemed to be no training for this nor a recognition as to who really was in charge.
4. There were two failures to report incidents under RIDDOR. Mrs Smither was involved in an incident concerning the use of a hoist, and she was injured. It apparently took the then owners 11 months to report that incident to the Environmental Health Dept. On the occasion of the choking which led to her death, again it took over a week for this to be reported. The guidance document entitled “RIDDOR Explained” does say where there is a death or major injury, it must be reported without delay (e.g. by telephone) and a completed accident report form must follow within ten days.