On 13/02/2017 commenced an investigation into the death of William Joseph WILSON. The investigation concluded at the end of the inquest 8th June 2017. The conclusion of the Inquest was Mr Wilson was enjoying a meal at the Church Inn on the 26th November 2016 when he suddenly choked as 3 result of a piece of steak becoming lodged in his throat: He was asphyxiated and suffered a fatal hypoxic brain injury and died at The Meadows, Stepping Hill Hospital on the Znd February 2017_ Hypoxic Brain Damage Choking Hypertension

Date Admitted: 26/01/2017 Consultant responsible for patient at time of death: Patient brought in by ambulance to the emergency department on the 26/1/2017 at 14.58 following a choking on a large piece of steak. Attended by paramedics within 4 minutes of choking and was resuscitated following which he expelled a large piece of steak. Unfortunately; he sustained hypoxic brain damage and was in coma a5 a result and following intensive care review it was considered that this was a terminal event and he was transferred to medical ward for end of life care: He was treated for aspiration pneumonia but deteriorated further with no improvement in his conscious levels. Following discussion with his daughter it was considered that palliative care would be provided in Bluebell where he died on the 2/2/2017 . Relevant PMH Hypertension

In my opinion action should be taken to prevent future deaths and believe vou have the power to take such action: