Inquest into the Death of Jeffrey Heyes Concludes Missed Opportunities

The inquest into the death of Jeffrey Heyes concluded on 1^st March 2024 before HM Area Coroner for Manchester West, Mr Peter Sigee.

Jeffrey died at the Royal Albert Edward Infirmary, Wigan, on 10^th January 2023. His death was caused by asphyxia due to accidental choking and was contributed to by pneumonia and a urinary tract infection.

Jeffrey was known to suffer from Parkinson’s Disease. He was admitted to hospital on 5^th January 2023 and was diagnosed and treated for urinary sepsis. He was assessed by a specialist Parkinson’s nurse on 6^th January 2023 who recommended that he be cared for on a ward specialising in care of the elderly as the staff would have additional experience, skills and training for patients such as Jeffrey, however, no beds were available on this ward and he was admitted to a general adult medical ward.

On 7^th January 2023, Jeffrey’s son visited him in hospital and found him asleep with food hanging out of his mouth. His son immediately informed staff, but this was not noted within Jeffrey’s clinical records and did not lead to any further review by the Parkinson’s nurse or the SALT team and no changes were made to his care plan.

On 10^th January 2023, Jeffrey was assessed and deemed fit for discharge. At approximately 12:40pm he was eating a sandwich and began to choke on the food he was eating. A nurse and doctor attended along with further staff. By this time, Jeffrey was in cardiac arrest. Efforts to clear his airway were significantly hampered because his jaw was locked in a closed position.

The Coroner found missed opportunities to provide additional and more timely care to Jeffrey during the resuscitation effort. There was a short delay in pressing the emergency alarm; the first suction device that was used didn’t work; an oxygen mask was not stored in its correct location and a decision was made not to attempt CPR because a do not attempt resuscitation decision was in place. As this was a potentially reversible condition, the hospital’s policy was that CPR should have been attempted. Jeffrey was already in cardio-respiratory arrest before the working suction device and oxygen masks were available, so by then these devices would not have been effective in the absence of effective CPR.

However, the Coroner could not determine that: (1) additional observations would have avoided the choking incident; or (2) additional or more timely care after he had choked on the food would have enabled a different outcome to be achieved.

The Coroner concluded that his death was an accident.

The family were represented by Alice Wood and Joseph Bridge of Farleys Solicitors and Alisan Hogg of 18 St John Street Chambers.