ROSEMARIE DEES, then aged 57 years, died on 18 April 2016. An investigation into her death was opened and an inquest held on 19 July 2016.

The inquest heard that Ms Dees had choked on a boiled sweet.

The medical cause of Ms Dees’ death was asphyxia caused by a food bolus in the larynx.

The conclusion of the inquest was one of accident.

The circumstances of the death are as follows: (1) Ms Dees had a range of pre-existing health conditions including COPD. There was evidence that this led to her often having a dry mouth/throat and coughing a lot. (2) Late in the evening of 18 April 2016 she was at home. Her son heard her banging loudly on the floor. He went to her and found her apparently choking on something. She lost consciousness. Her son began CPR and called the London Ambulance Service (“LAS”) who attended. The first LAS staff member arrived on scene at 00.03 am. (3) One of the LAS Paramedics used a Supra-Glottic Airway (“SGA”) (an I-Gel) to manage Ms Dees’ airway. (4) An Advanced Paramedic (“AP”) arrived and found that the SGA was ineffective, so she removed it. Upon removing the SGA the AP noticed a red, sticky, sweet-like substance stuck to the anterior aspect of it. (5) A further SGA was inserted followed by an Endo-Tracheal Tube using a video laryngoscope. (6) Advanced life support continued for 50 minutes. (7) Ms Dees’ life was pronounced extinct at 01.14 am.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are that the use of an SGA may be inhibited by an undetected foreign body airway obstruction. Such an obstruction might be spotted if the use of an SGA was made conditional on the carrying out of a laryngoscopy which it is understood will soon be LAS protocol.