Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of anti choking devices in care homes and restaurants
The earlier warning
Neville McKenzie · 24 Jan 2025 · Emma Brown, Birmingham and Solihull Districts
“[REDACTED], who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.”
judiciary.uk/…/neville-mckenzie-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Neville McKenzie (24 Jan 2025) · stated timescale: none stated
“I have set out below more detailed information on how health and safety incidents are regulated in the health and adult social care sectors in England and on regulatory responsibility in respect of medical devices.”
What recurred
- 10 Sept 2025 · Stuart Gilchrist · Lorraine Harris · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Neville McKenzie · 24 Jan 2025
“[REDACTED], who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.”
Later · Stuart Gilchrist · 10 Sept 2025
“During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name).”
What happened next
No web check of the stated actions has been published for this chain.