A BELOVED grandmother choked to death after being fed the wrong food in a care home.
Joan Whitworth died at the Oaks Care Home in Northumberland after staff prepared her meal in a way which “did not comply with her diet plan”.
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An inquest heard the 88-year-old had lived with her daughter Gillian but moved into the facility when her dementia progressed.
When eating a meal on March 3, 2023, Joan began to display signs of choking.
But the inquest heard how a care assistant did not intervene and had to ask another staff member for help to deliver back slaps and abdominal thrusts.
And, CPR was not performed due to the “inaccurate understanding of a registered nurse”.
Following the hearing, Northumberland’s senior coroner Andrew Hetherington has written a “prevention of future deaths” report.
The care home and NHS trust have 56 days to respond.
The coroner concluded Joan died “in a care home as a result of choking”.
And in his written report, he outlined a total of six “matters of concern”.
Of these, one was regarding the NHS trust and five were directed to the care home’s operator Hillcare.
The first issue was found with the speech and language team.
Joan’s assessment had not been written down in a formal report, meaning observations of her eating had only been passed on verbally.
The coroner also concluded that a nurse and care assistant at the home “were not in date with their training in Basic Life Support and First Aid at Work”.
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.”
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.”
Bryan added how the family had been “shocked and astounded by the quantity and severity of the mistakes” that were highlighted in the inquest.
He told how many families have shared similar “painful and shocking experiences”.
In a statement on behalf of the family read in court, they paid tribute: “Joan was a well loved character in Blyth. She was manager of Robson’s shoe shop and then moved to the Water Board.
“When we used to go shopping with Joan, it would take you an hour to get past the car park – as she knew everyone in Blyth with a tap or a pair of shoes!”
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.”