A care home resident choked to death after being served food that did not comply with her dietary requirements, an inquest has found. Joan Whitworth, 88, died at The Oaks Care Home in Blyth, Northumberland, on March 3, 2023, after staff gave her a meal she could not safely swallow.
The retired shoe shop manager had been living at the home due to worsening dementia. A coroner ruled that her death was caused by choking and identified multiple failings by both the care home operator, Hillcare, and the local NHS trust.
Senior coroner Andrew Hetherington found that the meal on the night of her death was prepared in a way that did not comply with her diet plan. A care assistant had to seek help before any emergency procedures, such as back slaps or abdominal thrusts, could be attempted. Cardiopulmonary resuscitation was not performed due to a misunderstanding over a do-not-resuscitate policy, though the coroner noted that equipment for resuscitation was unavailable and unlikely to have changed the outcome.
Mr Hetherington highlighted six matters of concern, including that staff training in basic life support and first aid was out of date, a chef was unaware that breaded fish was unsuitable for Mrs Whitworth's diet, and her speech and language assessment relied solely on verbal accounts from staff rather than direct observation or referral forms. A formal 'prevention of future deaths' report has been issued, requiring responses from both the care home and the trust within 56 days.
Mrs Whitworth's son-in-law, Bryan Smith, said the family pursued the case to prevent similar tragedies. He stated, 'We knew she hadn't been looked after.' A spokesperson for Northumbria Healthcare NHS Foundation Trust offered condolences but said they could not comment further due to confidentiality. A representative from The Oaks Care Home acknowledged the coroner's report and said changes had been made to procedures.
