Stuart Gilchrist
PFD Report
Partially Responded
Ref: 2025-0460
Coroner's Concerns (AI summary)
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
View full coroner's concerns
1. During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name). The care staff member, had recognised that Mr GILCHRIST was choking and while administering assistance to him had the foresight to ask if the restaurant had a “LifeVac” style device.
2. It was acknowledged during the inquest that restaurants have first aid items and some may have equipment such as a defibrillator however they may not be aware that this useful item exists, nor that it is relatively inexpensive.
3. At the time the evidence was heard, I was unaware of who would be responsible for advising restaurants and food establishments of the availability of such an item, or to raise with those outlets its usefulness should a customer begin to choke; so therefore this RPFD is sent to three organisations who may have varying levels of responsibility - without restaurants and food establishments being made aware of such an item, they may not think to purchase one and retain it within their first aid armoury.
4. I also appreciate that LifeVac is probably a trade name and I only use it to describe the type of item that would be deemed useful.
2. It was acknowledged during the inquest that restaurants have first aid items and some may have equipment such as a defibrillator however they may not be aware that this useful item exists, nor that it is relatively inexpensive.
3. At the time the evidence was heard, I was unaware of who would be responsible for advising restaurants and food establishments of the availability of such an item, or to raise with those outlets its usefulness should a customer begin to choke; so therefore this RPFD is sent to three organisations who may have varying levels of responsibility - without restaurants and food establishments being made aware of such an item, they may not think to purchase one and retain it within their first aid armoury.
4. I also appreciate that LifeVac is probably a trade name and I only use it to describe the type of item that would be deemed useful.
Responses
Noted
East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 be served to the HSE. (AI summary)
East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 be served to the HSE. (AI summary)
View full response
Dear ,
Further to our recent email correspondence in relation to the death of Stuart Gilchrist and the subsequent Regulation 28.
I am still waiting for contact from my link officer at the HSE, and will forward on the details if I am able to obtain an appropriate contact. I was unaware that
was the Chief Executive at the HSE, but I am sure that as this was sent to it will find its way to the appropriate person within their organisation.
To confirm the Local Authority does not have powers to specify the equipment that is provided in first aid kits. We also do not publish guidance on what should be provided in a first aid kit.
The Health and Safety (First-Aid) Regulations 1981 require employers to provide adequate and appropriate equipment, facilities and personnel to ensure their employees receive immediate attention if they are injured or taken ill at work. The equipment provided should be determined by a medical needs assessment. The HSE publish guidance on the Regulations and the guidance includes information on what first aid equipment should be included in a first aid kit. For this reason, I recommend that the most appropriate organisation to serve the Regulation 28 onto was the HSE as they publish guidance freely available to all businesses in the UK. Our Local Authority would signpost businesses to this guidance and would not provide specific guidance ourselves.
Furthermore, the Regulations cover first aid for employees only. There are no legal requirements for businesses to provide first aid to members of the public such as customers although it is recommended as best practice.
Please can I check if this response if sufficient and you can retract the serving of the Regulation 28? Or do you require a response within the require timeframe by the Councils Chief Executive? Please note that has left the Authority and the Acting Chief Executive is .
Please contact me on if you would like to discuss this matter further and I would be happy to assist.
Further to our recent email correspondence in relation to the death of Stuart Gilchrist and the subsequent Regulation 28.
I am still waiting for contact from my link officer at the HSE, and will forward on the details if I am able to obtain an appropriate contact. I was unaware that
was the Chief Executive at the HSE, but I am sure that as this was sent to it will find its way to the appropriate person within their organisation.
To confirm the Local Authority does not have powers to specify the equipment that is provided in first aid kits. We also do not publish guidance on what should be provided in a first aid kit.
The Health and Safety (First-Aid) Regulations 1981 require employers to provide adequate and appropriate equipment, facilities and personnel to ensure their employees receive immediate attention if they are injured or taken ill at work. The equipment provided should be determined by a medical needs assessment. The HSE publish guidance on the Regulations and the guidance includes information on what first aid equipment should be included in a first aid kit. For this reason, I recommend that the most appropriate organisation to serve the Regulation 28 onto was the HSE as they publish guidance freely available to all businesses in the UK. Our Local Authority would signpost businesses to this guidance and would not provide specific guidance ourselves.
Furthermore, the Regulations cover first aid for employees only. There are no legal requirements for businesses to provide first aid to members of the public such as customers although it is recommended as best practice.
Please can I check if this response if sufficient and you can retract the serving of the Regulation 28? Or do you require a response within the require timeframe by the Councils Chief Executive? Please note that has left the Authority and the Acting Chief Executive is .
Please contact me on if you would like to discuss this matter further and I would be happy to assist.
Noted
HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that the MHRA is responsible for regulation of medical equipment. (AI summary)
HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that the MHRA is responsible for regulation of medical equipment. (AI summary)
View full response
Dear Miss Harris,
REGULATION 28 PREVENTION OF FUTURE DEATHS – the death of Stuart GILCHRIST
Thank you for your Regulation 28 report of 10th September, in relation to the death Stuart Gilchrist, following a choking incident whilst dining at a restaurant with members of staff from the care home, at which he was a resident.
I would like to express my condolences to Mr. Gilchrist’s family and loved ones.
Your report raises as matters of concern, that had the restaurant had access to a Lifevac, or similar anti choking device, it might have been used to alleviate the choking in this incident. You report further concerns that restaurants may be unaware of the existence and potential uses of such devices, and about who might have responsibility to address this lack of awareness.
As a foundation for this response, I will firstly set out the health and safety legislation that covers responsibilities for workplace first aid provision, and actions employers must take to meet their responsibilities under this legislation.
The Health and Safety (First-Aid) Regulations 1981 require employers to provide such equipment and facilities that are adequate and appropriate to enable first aid for employees who are injured or become ill at work. These regulations do not apply to non- employees such as customers in a restaurant. The regulations do not prescribe the facilities or equipment that individual employers should provide, but require each
Miss Lorraine Harris Area Coroner East Riding of Yorkshire and City of Kingston Upon Hull
05 November 2025
Chief Executive Redgrave Court Merseyside L20 7HS Chief.executive@hse.gov.uk
employer to undertake a first aid needs assessment to determine the appropriate provision for that business.
There is no requirement within these regulations for employers to provide specific pieces of equipment such as anti-choking devices. HSE is not the responsible body for regulation of such medical equipment and it is not within our regulatory remit to approve or promote their use.
The Medicines and Healthcare Regulatory Agency (MHRA) is an Executive Agency of the Department for Health and Social Care (DHSC), with responsibility for the regulation and licensing of medical equipment and devices in the UK. MHRA Information on the licensing and use of anti-choking devices can be found here: Medical devices: information for patients - GOV.UK The guidance includes a link to the website of the Resuscitation Council UK, which has further information on the use of anti-choking devices.
Should you wish to raise your concerns with MHRA, you can make initial contact at: info@mhra.gov.uk
REGULATION 28 PREVENTION OF FUTURE DEATHS – the death of Stuart GILCHRIST
Thank you for your Regulation 28 report of 10th September, in relation to the death Stuart Gilchrist, following a choking incident whilst dining at a restaurant with members of staff from the care home, at which he was a resident.
I would like to express my condolences to Mr. Gilchrist’s family and loved ones.
Your report raises as matters of concern, that had the restaurant had access to a Lifevac, or similar anti choking device, it might have been used to alleviate the choking in this incident. You report further concerns that restaurants may be unaware of the existence and potential uses of such devices, and about who might have responsibility to address this lack of awareness.
As a foundation for this response, I will firstly set out the health and safety legislation that covers responsibilities for workplace first aid provision, and actions employers must take to meet their responsibilities under this legislation.
The Health and Safety (First-Aid) Regulations 1981 require employers to provide such equipment and facilities that are adequate and appropriate to enable first aid for employees who are injured or become ill at work. These regulations do not apply to non- employees such as customers in a restaurant. The regulations do not prescribe the facilities or equipment that individual employers should provide, but require each
Miss Lorraine Harris Area Coroner East Riding of Yorkshire and City of Kingston Upon Hull
05 November 2025
Chief Executive Redgrave Court Merseyside L20 7HS Chief.executive@hse.gov.uk
employer to undertake a first aid needs assessment to determine the appropriate provision for that business.
There is no requirement within these regulations for employers to provide specific pieces of equipment such as anti-choking devices. HSE is not the responsible body for regulation of such medical equipment and it is not within our regulatory remit to approve or promote their use.
The Medicines and Healthcare Regulatory Agency (MHRA) is an Executive Agency of the Department for Health and Social Care (DHSC), with responsibility for the regulation and licensing of medical equipment and devices in the UK. MHRA Information on the licensing and use of anti-choking devices can be found here: Medical devices: information for patients - GOV.UK The guidance includes a link to the website of the Resuscitation Council UK, which has further information on the use of anti-choking devices.
Should you wish to raise your concerns with MHRA, you can make initial contact at: info@mhra.gov.uk
Sent To
- Health and Safety Executive
- Food Standards Agency
Response Status
Linked responses
2 of 3
56-Day Deadline
5 Nov 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 13th June 2025 I commenced an investigation into the death of Stuart GILCHRIST, aged 77 years. The investigation concluded at the end of the inquest on 8th September 2025. The conclusion of the inquest was: ACCIDENT The following findings of fact were made: Mr GILCHRIST had a history of suffering with his mental health, and was therefore in a supported living care facility under DOLS. His past medical history included schizophrenia and Type 2 Diabetes Mellitus. These were originally included in his cause of death under section 2 but given the circumstances and mode of death they did not contribute to his demise and as such I do not feel they belong on the cause of death but rather in my Findings of Fact. Mr GILCHRIST had been very ill in Autumn of 2024 and been on a restricted diet, I find this was necessary and appropriate at that time. o When on a pureed diet, Mr Gilchrist did not like the presentation of his food, but he did eat it. Mr GILCHRIST was discharged from the Speech and Language Therapy Service (SALT) – the team that gave advice re diet - in January 2025 following observations in December 2024. This again was appropriate. In May 2025 Mr GILCHRIST choked on a bacon sandwich. The Care Home sought medical attention which advised observations and issued antibiotics with regard to any residual chest infection. The Care Home did the right thing by referring for medical attention. o Had they referred the matter to SALT then a telephone assessment would have taken place. In the circumstances and with hindsight, this would have been best practice. However, given that a telephone consultation would have taken place and it would have been reported that, bar this incident, Mr GILCHRIST had been coping on a normal diet, I find that it would not have made a difference to Mr GILCHRIST’s diet at the time of his death. On the day of his death, Mr GILCHRIST was on a trip out with care home staff and other service users. The staff to service user ratio was appropriate. It is worthy of note that Mr GILCHRIST was in an area that was very dear to him. When Mr GILCHRIST’s food arrived, it was cut up appropriately and he was in sight of staff during the meal. As soon as Mr GILCHRIST’s demeanour changed it was spotted in a timely manner by care home staff. Immediate and appropriate first aid was given by way of back slaps following by abdominal thrusts, both of which were unsuccessful. Emergency services were called immediately and staff conducted cardio-pulmonary resuscitation (CPR). Staff called for a “LifeVac” suction device which is available in many care homes but not necessarily available in restaurants, one was not available. Paramedics arrived and used forceps and a laryngoscope to remove a large amount of potato and meat from Mr GILCHRIST’s airway. CPR continued and he was conveyed to hospital. RPFD – I will make a report to those who have oversight for safety in Restaurants regarding the usefulness of LifeVac type facilities. Box 3 of the record of inquest read: On 11th June 2025 Stuart GILCHRIST, aged 77 years, attended a restaurant for lunch with staff and other service users from his care home. During the meal Mr GILCHRIST stood up from the table and it was evident that he was unable to breath. Despite prompt assistance from staff with back slaps and abdominal thrusts, Mr GILCHRIST collapsed and cardiopulmonary resuscitation (CPR) was immediately commenced. An ambulance attended and removed food from his airway, they continued with CPR but on arrival at Hull Royal Infirmary Mr GILCHRIST was in cardiac arrest. CPR was continued but unsuccessful and Mr GILCHRIST was declared deceased that day. His medical cause of death was recorded as: 1a Hypoxic Brain Injury 1b Choking
Circumstances of the Death
In June 2025 Stuart GILCHRIST was out with carers and other service users from his care home when he choked while eating lunch at a restaurant. He had previously been on a restricted diet due to swallow issues following ill health in Autum 2024 but since December 2024 been deemed suitable for a normal diet and discharged from the SALT team in January 2025. He did have one further episode of coughing/choking on food in May 2025. Medical assistance was sought, SALT were not contacted for a re-referral. Care staff did all they could to assist Mr GILCHRIST with back slaps, abdominal thrusts and eventually CPR. During this assistance the Care Staff member asked if the restaurant had a LifeVac style device, which is an inexpensive item that can help remove items from someone’s airways. This device is available at the Care Home. The restaurant did not have one.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.