A carer ‘assumed’ a vulnerable man who choked to death while eating a sandwich was sleeping, a coroner said.
Craig Spiby, who had a rare disorder that made him susceptible to choking, collapsed while eating his lunch at a care home for adults with learning difficulties in Farnworth, Bolton. Despite having a care plan that stipulated he should be monitored while eating, the 49-year wasn’t discovered ‘for a significant period’.
Paramedics were called to the home, but Mr Spiby was pronounced dead. Following an inquest in Bolton, which concluded Mr Spiby died due to an accident contributed by neglect, coroner Timothy Brennand warned Bolton Cares, the Bolton council-owned company which runs the care home, to make a series of improvements.
In a prevention of future deaths report, Mr Brennand wrote: “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 July 13, 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 raised concerns about the lack of confidence expressed by staff in the emergency first aid training 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’.
The chief executive of Bolton Cares has until February 4 to respond to the report, which has also been sent to Bolton council and the Care Quality Commission.
A spokesperson for Bolton council said: “This is an incredibly sad case, and our thoughts remain with Craig Spiby, his family and friends, and all those affected by his tragic death.
“As the owners of Bolton Cares, we’ve worked closely with all agencies to understand what happened and we fully accept the findings of the coroner’s report. Immediate actions were put in place as soon as the incident occurred, and work is underway to address and action any further points raised by the coroner’s office to ensure we provide the highest possible standard of care.”
Bolton Cares have been approached for comment.