Joan Whitworth
29 Jul 2025 · Coroner Andrew Hetherington · Northumberland
The coroner's concerns
1. swallowing risk due to inadequate assessment
“Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records.”
2. untrained staff in basic life support and first aid
“Basic Life Support and First Aid at Work”
3. inadequate nutritional risk assessment and management
“I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment.”
4. delayed response to choking by agency staff
“I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction.”
5. inappropriate food provision despite diet plan
“Normal Diet IDDSI L7 easy chew and to avoid difficult textures.”