Inadequate training and record keeping led to a care home resident’s death from choking, an inquest has heard.
Joan George died at Priory Adult Care’s Abbey Court Care Home in Bourne, Lincolnshire, on September 28, 2016 after choking on a piece of bread.
An inquest at Lincoln’s Cathedral Centre heard staff failed to act when Mrs George began to choke on a sandwich, LincolnshireLive reported. The pensioner was pronounced dead at the scene after paramedics arrived at the care home.
The inquest heard that “inadequacies of training and inadequacies of record keeping”, as well as general practices and procedures that were “not robust enough”, had led to Mrs George’s death.
Staff initially carried out a choking risk assessment of Mrs George, who was living with dementia, shortly after her admittance to the home.
Despite the assessment finding an increased risk of choking, this was not reflected in her care plan.
Care assistant Ahibo Attekeble, who no longer works at Abbey Court, told the inquest that she had broken up the sandwich into little pieces before giving it to Mrs George.
She admitted she had been unable to help the resident when she began choking due to a lack of specific first aid training.
Duty nurse Neil Wright said he administered back-slaps and the Heimlich manoeuvre to no avail before calling 999.
Mrs George’s daughter-in-law Mandy, said: “It’s a bit of a relief that we have got a bit of justice for Joan. There were major issues.
“We wish she had died more peacefully as her final moments were not very peaceful and we have got to live with that.
“She shouldn’t have had to lose her life for improvements to be made.”
A spokesperson for the home said: “We would like to extend our deepest sympathies to Joan George’s family. Staff have received further specialist training and staff handovers have been improved. The home was rated ‘good’ overall and in all assessment categories following its latest inspection by the Care Quality Commission.”