Walter Willows
PFD Report
Historic (No Identified Response)
Ref: 2015-0218
Coroner's Concerns (AI summary)
Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.
View full coroner's concerns
During the course of the inquest hearing was told, inter alia, that the Care Plans for such clients were reviewed on a three monthly basis. This included their specific feeding regimes. In the case of Mr Willows it was apparent that this should have been looked at far more frequently so as to adjust his diet to suit his swallowing ability. took the view that these Plans (and especially that part relating to feeding) should be examined more frequently and it was within the power of yourselves to arrange for this to happen.
Sent To
- Westwood Homecare Limited
Response Status
Linked responses
0 of 1
56-Day Deadline
5 Aug 2015
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 10th October 2014 commenced an investigation into the death of Walter Willows dob 19"h December 1937 The investigation concluded on the 24th February 2015 and the conclusion was one of Accidental death: The medical cause of death was Ia asphyxia 1b Choking on food 11. Coronary Artery Atheroma
Circumstances of the Death
On the 3rd October 2014 he was at his home address_ He ate a crumpet and choked: This led him to asphyxiate.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.