A coroner has warned the Bolton company which runs a series of care homes for adults with learning difficulties to make improvements following the death of a resident.
Craig Spiby was a local authority-funded resident at one of Bolton Cares’ facilities in July 2024. The 49-year-old suffered from a rare and debilitating chromosomal disorder called Phelan McDermid Syndrome that rendered him susceptible to choking.
Despite his care plan stipulating that Craig should be monitored while eating, he collapsed while eating a sandwich, and his condition was not discovered “for a significant period”. He was pronounced dead by paramedics at 12.23pm.
An inquest, which took place last month, concluded that Craig died due to an accident contributed by neglect.
In his conclusion, Manchester West’s Senior Coroner Timothy Brennand said: “The deceased suffered from Phelan McDermid Syndrome – a rare and debilitating chromosomal disorder, that amongst other symptoms, rendered him susceptible to choking on food and liquids at mealtimes.
“From 2009, the deceased’s extensive health care needs were being met actively upon him becoming at full time resident at a locally authority funded assisted living facility at [REDACTED], Farnworth.
“On the 13th of July 2024, when eating his lunch whilst unsupervised and only indirectly monitored in the kitchen of the residence, he rapidly became collapsed and unresponsive having inadvertently choked on a sandwich.
“His condition was not appreciated for a significant period, the duty carer on returning to the kitchen erroneously assumed the deceased had fallen asleep until later realising the deceased was totally unresponsive. Despite prompt attendance and attempted resuscitation by emergency paramedics, he failed to respond and at 12.23pm that day was pronounced dead.
“A post-mortem established the deceased to have choked on a bolus of masticated sandwich that had lodged in his windpipe that would have caused hypoxic driven cerebral malfunction and potential loss of consciousness within four minutes and irreversible cardio- respiratory failure within 10 minutes.”
The coroner has this month issued a Prevention of Future Deaths report which requires the company which runs the care home, Bolton Cares, to take steps to prevent similar incidents. Bolton Cares must respond within 56 days.
The coroner raised concerns about the lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case and “how and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe”.
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