A recent Inquest into the death of a 76 year old care home resident has revealed a series of failings by staff, both at Laurel Court Care Home in Didsbury, Manchester, and at Manchester Royal Infirmary (MRI).
Mr John Forrest, a former clerk at AstraZeneca, had been a resident at Laurel Court Care Home for eight years prior to his death. He suffered from dementia. He was admitted to the MRI on the 27th April 2012 with a urinary tract infection and was discharged on the 4th May 2012. Mr Forrest collapsed after choking on fish and chips fed to him by the nursing home despite clear instruction in the discharge summary that he could not swallow solid food and would require pureed food. He was taken to hospital but died the following morning.
An Inquest into his death was held at the Coroner’s Court in Manchester before Deputy Coroner Jean Harkin. She gave a narrative verdict after finding a number of failings by staff both at the care home and the hospital had contributed to Mr Forrest’s death.
Failings by Laurel Court Care Home
Evidence from staff at the care home confirmed that following his discharge from the MRI, Mr Forrest arrived at the care home during the ‘busy’ tea time service. He was taken directly to the dining room where he was given the evening meal of fish and chips. In the meantime, the nursing unit manager, Mrs Abigail Mbizi, read the hospital’s discharge summary which gave clear instruction that Mr Forrest was not to be fed solid food and immediately went to inform her colleagues. Unfortunately by this time, Mr Forrest had already begun choking.
During the Inquest, Mrs Mbizi accepted that she had failed to document a telephone conversation she had taken a few days earlier from the MRI staff which detailed that Mr Forrest was struggling to swallow and as such would require pureed food upon his return.
Care home manager, Mr Lance Tipper, stated;
“At the time of the incident we were going through a significant refill of staff. We were undergoing training but it wasn’t consistent…Procedures were in place but the handover took place in our busy tea time period. It would normally have been at a time where he could have been admitted more calmly.”
Failings by the MRI
One of the doctors at the MRI placed a ‘Do Not Resuscitate’ Order on Mr Forrest without consulting him, his solicitors, or indeed the care home.
Mr Forrest, despite suffering from dementia, was deemed to be an intelligent man and ought to have been consulted about such a decision. If this had become inappropriate, it would certainly be necessary to attempt to contact his solicitors or indeed the home.
Outcome of the Inquest
Deputy Coroner Jean Harkin, found a number of failings by both the home and the hospital. She recorded a narrative verdict and pledged to write to MRI in respect of the ‘do not resuscitate’ order on Mr Forrest without his consent, nor the consent of other appropriate authorities.
Praise was given by the deputy Coroner to the hospital trust and to the care home for ‘identifying and rectifying’ failures in their handover policy which led to Mr Forrest’s death prior to the Inquest.
However she did state during her narrative verdict that there was a series of failures from both the MRI and Laurel Court. She also stated that Mr Forrest’s death was ‘very tragic’ and ‘could have been avoided’.
How we can help
Here at Farleys we have a team specialising in Inquests where a loved one may have died as a result of medical negligence and have represented many families in inquest proceedings concerning various local and national hospitals. Often, meetings with senior healthcare managers following the death of a loved one can be extremely daunting and overwhelming. Our Inquest team is on hand to attend these meetings with you and put forward your concerns. We will guide you through the inquest process and ensure that you secure the answers to the many questions you will undoubtedly be faced with. Together, with our medical negligence solicitors, we will ensure that all possible avenues of enquiry are explored and assist you in obtaining civil damages for the death of a loved one.
If you would like to speak to a solicitor about claiming compensation for the mistakes or negligence of a medical professional, please contact us on 0845 050 1958 or email us.