Coroner orders changes at care home after avoidable choking death
Mandeville Grange Nursing Home told to improve policies, training, and incident investigations following the death of an 80-year-old resident who choked on a piece of toast
A coroner has issued urgent recommendations to Mandeville Grange Nursing Home after an inquest found serious failings that contributed to the avoidable death of an 80-year-old resident.
Sheila Nicholls choked on toast in November 2023, a day after entering the home for respite care.
An inquest which concluded in October 2024, found that Shelia's death could have been avoided if staff at Mandeville Grange Nursing Home had properly communicated her dietary needs and been adequately trained in emergency response procedures.
The inquest, led by Assistant Coroner Michael Walsh for Buckinghamshire, revealed that Sheila had a known swallowing difficulty, which her family had communicated to the nursing home.
However, this information was not recorded or shared with relevant staff. As a result, Sheila was served toast for breakfast, which she choked on, leading to hypoxia and a cardiac arrest.
The coroner’s narrative conclusion stated: “Sheila choked on food during a short period of respite care. Information on Sheila’s swallowing problem was provided to the nursing home staff by family members, but the nursing home’s assessments and checklists and handovers either omitted or did not share that information or the risk it presented, with all relevant staff. Breakfast was therefore given to Sheila that did not take her swallowing problem into account.”
Emergency assistance during the incident was described as inadequate. Of the staff who responded, only one had valid life support training, which was deemed insufficient, as the CPR performed was ineffective. Furthermore, the nursing home did not conduct simulated emergency drills, and some staff were unaware that their training certifications had expired.
The coroner raised concerns about deficiencies in the management and communication of internal policies, including the use of undated and unsigned documents, poor version control, and a lack of confirmation that policies were read and understood by staff.
He also highlighted shortcomings in the investigation process following Sheila’s death, noting that internal reviews conducted by untrained staff failed to address critical issues. The nursing home has since expressed an intention to use external investigators for future incidents.
The report concluded that these failings created ongoing risks for residents and called on Mandeville Grange Nursing Home to take immediate action to prevent further deaths.
The nursing home must respond to the coroner’s report by 5 March 2025, outlining steps to address these concerns.
We have approached Chiltern Care Services who run the home for a comment.