The death a man who choked on food at an Oswestry residential home was “accidental” and not “reasonably preventable”, an inquest jury has found.
Colin John Jones died of hypoxic brain injury after choking on food on January 11th, the inquest at Shrewsbury’s Shirehall was told yesterday.
The 56-year-old, who was a retired taxi driver, was rushed from the Laurel Ward of Hengoed Park to Royal Shrewsbury Hospital, where he was pronounced dead at about 9am the following morning.
It followed a previous choking incident on January 3rd, although medical staff said they had made no changes to how he had been cared for.
Other causes of death included cardiac arrest and airway obstruction. Secondary causes were early onset dementia and smoking.
He had got food on January 11th before returning to his room, the inquest heard. Medical staff found him unresponsive about an hour later, at 6pm, holding a jug of water which had emptied onto the floor.
They tried to resuscitate him, and tried to clear his airways of food. Other than on January 3rd, the jury heard there had been no recorded issues with Mr Jones’ swallowing or problems with his food. He had a habit of drinking too much water, which those caring for him were monitoring.
The January incident was not seen as serious, although Mr Jones had been recommended to visit speech and language therapy to be checked over.
The recommendation was “not actioned”.
A jury yesterday concluded his death had been “accidental” and it was not believed his death had been “reasonably preventable”.
During the inquest, assistant coroner Joanne Lees listened to evidence by Rachel McKeown, director of Allied Health Professions for Midlands Partnership NHS Foundation Trust, who investigated issues surrounding Mr Jones’ referral to see a speech and language therapist.
She said a substantive therapist is now in place, rather than locum support, new guidelines have been brought in and procedures have changed.