A DEMENTIA sufferer choked to death at a Hampshire care home just months after inspectors reported concerns about how she was being fed, an inquest heard.
Eileen Taylor died three months after inspectors from the Care Quality Commission (CQC) observed her eating a meal and raised the alarm over the lack of pureed food despite the 87-year-old being an “extreme risk” for choking.
Care bosses were so concerned about the failings at Woodlands House in Fordingbridge, they stopped placing people there before her death and the home eventually closed in February after going into liquidation.
Southampton’s coroner ruled this was a death that “should not have taken place” and warned that “slap dash” care plans put vulnerable patients at risk.
Mrs Taylor was having lunch in August last year, when she started having difficulty swallowing and she collapsed and died, despite attempts to resuscitate her.
At the time of the incident there were 12 patients needing support with their meal, with one carer in the dining room.
Southampton Coroner’s Court heard how this was the second time Mrs Taylor had suffered from a choking incident and that the care home, in Main Road, was under investigation at the time by the CQC.
They had been called in by Hampshire County Council in May after they became concerned about the cleanliness of the home as it smelt of urine, failure to cater for resident’s specific individual needs, lack of record keeping and management of medication.
The home was found to be failing in a number of standards and was ordered to take immediate action as they felt the home was not “ensuring the health and welfare” of residents.
Collette Puntis, safeguarding adult co-ordinator for Hampshire Adult Services, told the hearing that due to poor care plans, there was confusion among staff about how food should be prepared for Mrs Taylor and how much supervision she should have.
She said: “The instructions were not clear or consistent or specific enough. The care staff really weren’t being directed adequately.”
She added that some changes had been made after the CQC inspection but that there was still “confusion” over the information in the rewritten care plans.
The court also heard that the service needed investment to provide the improvements within the time frame requested but the facility went into liquidation and closed earlier this year.
Coroner Keith Wiseman said: “This was a death that should not have taken place in these particular circumstances.
“It was clear that a high level of supervision was required and that wasn’t provided.
“High standards must be kept because very vulnerable people are being dealt with and there’s simply not the scope for any that is slap dash in terms of records and important documents recording individual needs.”
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