Joan Whitworth, 88, choked to death after she was given a meal ‘that did not comply with her diet plan’ in her care home, a coroner said – staff gave her breaded fish she couldn’t safely eat
A much-loved grandmother tragically choked to death after she was given the wrong food at a care home.
Joan Whitworth, 88, sadly died when staff at the care home she was in gave the popular resident food they should have known she could not swallow. The grandma, who was a retired shoe shop manager, had lived in the Oaks Care Home in Blyth, Northumberland, due to her worsening dementia.
Joan sadly died on March 3, 2023, and a coroner ruled she passed away “in a care home as a result of choking” and said the care home and NHS trust had to make changes to prevent a death like this from happening again. It comes after a dad died in a scalding hot bath as his family slam the hotel’s management for ‘ignoring warnings’.
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Northumberland’s senior coroner, Andrew Hetherington, said Joan’s meal on the night she died “was prepared in a way that did not comply with her diet plan”. The coroner added: “She began to experience symptoms of choking as a result of massive aspiration of which she was at risk of.”
During the inquest, the coroner said he heard evidence as to how a care assistant had then needed to seek help and another member of stuff needed to arrive before “back slaps” and “abdominal thrusts” could be attempted, according to the ChronicleLive.
The coroner further explained that CPR was not then attempted due to “inaccurate understanding of a registered nurse” when it came to “do not attempt CPR” policies.
However, he added: “The equipment [to attempt to resuscitate Joan] was not available and is unlikely to have altered the outcome.” Hetherington then highlighted a total of six “matters of concern” – one addressed towards the NHS trust and five towards the care home’s operator Hillcare.
The first issue – with the speech and language team – was that Joan’s assessment had relied on the verbal account of a member of care home staff, rather than information provided in a referral form or observation of her eating.
The issues with the care home’s operations included a nurse and care assistant “were not in date with their training in Basic Life Support and First Aid at Work”, that there was a lack of training and inductions for staff.
The coroner added: “I am concerned that a chef in evidence at the inquest was not aware that breaded fish was not a suitable food stuff in the diet identified for the deceased. I am concerned that other residents could be fed inappropriate food stuffs that are not in line with their identified diet plans.”
The coroner produced a formal “prevention of future deaths” report which both the care home and NHS trust must respond to within 56 days.
Bryan Smith, Joan’s son-in-law, told ChronicleLive: “Right from the start, we knew what had happened – that they hadn’t given her the right food. We knew she hadn’t been looked after. The reason we have pursued this is that we knew what had happened.
“We thought this sort of thing could happen time and time again unless people are taken to task. The coroner can’t apportion blame, but he can and did look at how things came to happen.” Bryan said the family was happy by how the coroner had handled Joan’s case. He added: “We were quite surprised, you never really think these things are going to come out positively.”
A Northumbria Healthcare NHS Foundation Trust spokesperson said: “All referrals to our speech and language therapy service are robustly triaged using a risk and evidence-based approach to inform the most appropriate care for that individual.
“This includes information on the referral form and discussion with the patient and / or those who care for them daily to gather the most up-to-date information. We cannot comment further on this case due to patient confidentiality, but would like to offer our sincere condolences to Mrs Whitworth’s family and loved ones.”
A spokesperson for The Oaks Care Home said: “We acknowledge the Coroner’s report relating to the death of Joan Whitworth at our home in March 2023. Our thoughts remain with her family and loved ones.
“Following the incident, we carried out a full review and made all necessary changes to our practices and procedures. These have been in place for some time and will be reflected in our formal response to the Coroner’s report. The safety, dignity, and wellbeing of those in our care remain our highest priorities.”