A coroner has warned more deaths could occur at a mental health hospital where three people died from choking on food.
Ravi Sidhu has written to Prospect Park Hospital in Reading with concerns about staff communication, training, and the care of patients at risk of choking.
It comes after evidence in a patient’s inquest raised “matters of concern”.
The hospital said a “number of changes to practice” had been made since the inquest, but added it would “give careful consideration” to the report.
The hospital has dealt with six choking incidents from which three people died in a year.
Anne Roberts, 68, was one of the patients who died from choking in September 2017
Miss Roberts was placed on a soft food diet because she was deemed to be at “high risk” of choking, Reading Coroner’s Court heard.
The inquest was held at Reading Town Hall
A soft-food diet is classified by the hospital as food that is pre-mashed or well soaked. Despite this she was given chocolate cake, which was not on her permitted diet.
The grandmother had previously choked on food on two other occasions before her death.
‘Lack of common sense’
The inquest, presided over by Berkshire’s assistant coroner, Mr Sidhu, found areas of care at the hospital were inadequate, which contributed to the retired cleaner’s death.
In a report to Berkshire NHS Trust, Mr Sidhu said there was a risk that “future deaths could occur unless action is taken”.
Roberts was eating a piece of chocolate when she choked at Prospect Park Hospital in Reading
The coroner outlined his four “matters of concern” from the inquest:
- Mr Sidhu said he was concerned about the training of staff “in relation to the care of patients at risk of choking, including patients who are mentally ill”.
- He raised concerns about the “dissemination of information” to ensure “hospital records are full, accurate and up to date”.
- He said actions needed to be taken in relation to how “risk of of choking is managed when patients eat in their bedrooms”.
- The coroner added frontline ward staff needed training “around the interaction between mental disorders and choking risks”.
The trust has 56 days to respond to the report.
Christie Dyball, Miss Roberts’ daughter, said staff had shown a “lack of common sense” in caring for her mother.
In a statement released after the inquest, the trust said “changes had been made” ahead of the hearing following criticism from the Care Quality Commission.