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Dechoker UK chokeaware
  • Dechoker UK chokeaware

    Care Home Resident Choked and Died after DNAR confusion

    AN INQUEST has heard how an 80-year-old care home resident choked to death, after confusion over how to respond because a DNAR was in place.

    Robert Murray was eating breakfast at the Avalon Nursing Home in Eastbourne, East Sussex when he began to choke. An apparent lack of awareness meant no ambulance was sent and the resident later died.

    Mr Murray suffered from mile dementia and was cared for at the home when he was eating breakfast in June last year when the incident happened. A later autopsy found a food bolus in his airways.

    During the course of the investigation HM Senior Coroner, Alan Romilly heard the 999 call between the registered nurse and the operator which gave rise to his concern.

    Published as part a Regulation 28 Report the coroner said;

    ‘From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied.

    Alan Romilly CRAZE, HM Senior Coroner for the coroner area of East Sussex

    The Coroner also went on to register concern that this may well be an issue elsewhere in the country, and that further training and clarification is therefore necessary. In addition he has also written to a number of organisations including the Care Quality Commission, NHS England and the Resuscitation Council UK.

    There is already clear guidance on how to manage a DNAR / DNACPR in a choking emergency published some years ago.

    You can find out more about how to manage choking when a DNAR is involved here.