Prabhaker Nath Kapoor · Prevention of Future Deaths report

On 17/05/2019 I commenced an investigation into the death of Prabhaker Nath Kapoor. The investigation concluded at the end of an inquest on 5th August 2019. The conclusion of the inquest was that of a Narrative Verdict, namely, “death due to aspiration of unthickened fluids in hospital.”

On 19/11/18, the deceased had an unwitnessed fall at home and was admitted to the Emergency Department at Birmingham Heartlands Hospital where he was diagnosed with a fractured neck of the right humerus. He was admitted to Ward 24 where the fracture was to be treated conservatively using a brace. He developed pneumonia due to aspirating food and was treated with IV antibiotics. He had previously been assessed in March 2017 by speech and language therapists in the community for a pureed diet and thickened fluids due to dysphagia caused by previous stroke, and a Feeding At Risk form was completed upon admission to Ward 24 on 19/11/2019 for this diet to continue. At 04.55 on 21/11/18, he was found by a member of staff attempting to drink from an unthickened jug of water which had been left near his bedside. He aspirated an unknown quantity of the contents which contributed to his aspiration pneumonia. His condition rapidly deteriorated as a result of this, and despite appropriate treatment, he died and his death was verified at 08.10 on 21/11/18..

Following a post mortem, the medical cause of death was determined to be:
1a) ASPIRATION PNEUMONIA
1b) INHALATION OF LIQUID
2) FRAILTY

I heard evidence that a review of safer swallowing training was to be provided to staff on team training days, and that changes would be made to the MOODLE training package by the Speech and Language Manager. The RCA report carried out by Matron ████████ indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me. Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package as a matter of urgency.