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Inquest jury finds a number of 'inadequacies' at Bourne care home led to pensioner's death




An inquest jury found a number of "inadequacies" at a Bourne care home led to a pensioner choking to death on a sandwich.

The jury foreman at the inquest of Joan George, 73, who died on September 28, 2016 at Abbey Court Care Home said there were "inadequacies of training, inadequacies of record keeping" and that general practices and procedures were "not robust enough".

Joan George (8104656)
Joan George (8104656)

The narrative verdict was delivered at the end of the three-day inquest at the Cathedral Centre in Lincoln, led by Marianne Johnson, assistant corner for Lincolnshire.

She offered her condolences to the family and said the verdict hopefully meant' they 'could move on'.

Mrs George was admitted to Abbey Court Care Home on Falcon Way on August 24, 2015 and her inquest on Monday opened with a number of statements, including one from a pathologist who confirmed there was evidence of food obstructing Mrs George's airways. A post-mortem examination concluded that the cause of death was choking, dementia and cerebral contusions.

The oral evidence got underway with care assistant Ahibo Attekeble.

Attekeble, who was feeding Joan the sandwich she choked on, said she had not received specific training on what to do if someone started choking.

After eating around three quarters of the sandwich which had been torn up into small pieces, Mrs George, who was in bed at the time, began choking.

The inquest was told she started making a grunting-like noise and was reaching out with her hands.

Ms Attekeble, who no longer works at Abbey Court, then called out for her colleagues and went to press the emergency button.

Neil Wright, who was the duty nurse that evening, responded to the emergency bell and told the inquest he did back-slaps and the heimlich manoeuvre to no avail before calling 999, where the operator instructed him to perform stomach presses, but again this was to no avail.

When the operator instructed him to do CPR, he said Mrs George had a do not resuscitate order so CPR was not performed.

Paramedics arrived and pronounced her dead at 10.54pm, shortly after arriving.

The inquest also heard from care assistants Inot 'John' Geanana and Luke Masterson, who no longer work at Abbey Court and responded to the call for help.

The both said that Mrs George was lying in bed at a 45-degree angle and between the two of them, managed to get some pieces of the sandwich out of her throat.

On the second day, the inquest heard a statement from Sue Jeavons, a manager from East Midlands Ambulance, who confirmed that a 999 call was made by Mr Wright at 10.38pm.

Annabel Marshall, deputy manager at Abbey Court, said that after Mrs George came back to the home from a two-day stay in hospital following a fall on September 17, the nurses had assured her there were only problems with her mobility.

It was known that Mrs George ate slowly and required assistance with food but there was no evidence of choking or swallowing difficulties before her death,

However, a choking risk assessment carried out on September 21, found that although still considered a low risk, Mrs George's score had increased from two to 13 but this was not reflected in the care plan.

Marshall also said that Ahibo Attkeble had not read Mrs George's care plan or attended the shift handover.

She said that Abbey Court has "embedded the lessons learned" from the pensioner's death.

Sarah Mann, associate director of nursing at Priory Adult Care, which owns Abbey Court, said procedures and staff training had improved after Mrs George's death.

She said staff had basic life support training once a year instead of once every three years and this included dealing with residents who were choking.

Handovers between staff were also improved.

A new assessment called 'supporting service users with swallowing difficulties' had also been implemented along with a 'much greater focus' on documentation and keeping it up to date.

There was also clearer information produced about each resident so the care assistants were more aware of residents' needs along with a 'resident of the day'.

This sees one resident of each wing at the care home focussed on, making sure everything to do with them is in order.

Annnette Wakeford, principle practitioner of adult safeguarding at Lincolnshire County Council, told the inquest that she and a team from the safeguarding team had visited the home on a number of occasions after Mrs George's death.

She put forward four recommendations to the care home:

  • Staff would benefit from further training in writing reports
  • Communicating with relatives more effectively
  • Clarification in regards to do not resuscitate orders
  • Further training in writing comprehensive care plans

In response to this, Ms Mann, said that steps were being taken to address all of these recommendations.

Training had commenced into writing reports, relatives meetings were held once a quarter, staff had been made more aware of do not resuscitate orders and that there would be much more cross-referencing between care plans and risk assessments.

Mrs George's family concluded the second day's session with an emotional tribute to much-loved Joan.

They said she was "important to us" and explained how devoted she was to husband Frank, her two children and grandchildren along with her wider family.

The inquest ended with the narrative verdict today (March 27).



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