An inquest heard that tragic pensioner Philip Jones, 92, died after choking on dental gel he used to keep his dentures in place – the coroner expressed concern that such a gel can become ‘lodged deep into the respiratory system’
A coroner has issued a warning after a pensioner choked to death on the gel he used to secure his dentures, an inquest heard.
Paramedics tried to save Philip Jones, 92, but found the ‘thick’ gel which had become trapped in his airway ‘extremely difficult to remove’, the hearing was told. Now Richard Middleton, Assistant Coroner for the area of Dorset, has raised concerns that there were no choking hazard warnings on the gel’s packaging.
The inquest heard that Mr Jones was diagnosed with dementia at the age of 90 in August 2022. He moved into Southbourne Beach Care Home in Bournemouth, which specialised in dementia care, the next month.
On his arrival risk assessments were carried out including for choking hazards, and a care plan was made which included oral care. Mr Jones had his own room and en suite facilities, and was permitted to care for himself, except for being prompted.
He also had the support of one member of staff with his personal care. The inquest heard: “He had capacity to make daily non-complex decisions.
“He wished to maintain his independence as far as possible with all aspects of his daily care needs.
He was able to manage elements of his own daily personal care which included oral care.”
“Mr Jones had upper and lower dentures which he secured in place on a daily basis using an adhesive gel. He had daily access to this gel which was stored in his bathroom cabinet.
“There were no reported concerns regarding his daily access to the adhesive gel. The gel and other toiletries were provided by his family.”
The inquest found there was no warning on the box or enclosed leaflet of the ‘thick adhesive gel’ suggesting it was a potential choking hazard – this concerned the coroner.
Mr Middleton’s prevention of future deaths report, published in February 2025, said: “A member of staff found Mr Jones in his room with denture adhesive gel in his mouth, ears and nose.
“Attempts were made to remove the substance from his mouth.
“Mr Jones’ breathing became laboured and paramedics attended and took him to hospital where his health deteriorated and he died.”
The pensioner’s autopsy revealed the gel had completely blocked part of his upper airway, and went down to the bronchus of one of his lungs. Mr Jones’ medical cause of death was hypoxic brain injury, choking, inhalation of adhesive gel and dementia. Mr Middleton recorded a verdict of accidental death.
But writing to the CEO of dental company Fixodent and the Care Quality Commission (CQC), he expressed his concern that such a gel can become ‘lodged deep into the respiratory system and can be extremely difficult to remove’.
The coroner added that products like this are likely to be used by the older generation and people ‘suffering from a decline of brain functioning’.
He suggested that products like this should therefore be considered in risk assessments for people living in care homes, and noted his concern that there is no warning on the product about the risk of choking.
Fixodent and the CQC must respond to the coroner’s report by April 24 2025.
