Dorothy Clarkson
PFD Report
Historic (No Identified Response)
Ref: 2014-0465
Coroner's Concerns (AI summary)
Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
View full coroner's concerns
(1) the procedure by which food is provided and presented to residents who require food to be prepared in a certain way and who need assistance by virtue of their physical or mental condition; and (2) a lack of training appropriate to nursing staff working in a nursing home undertaken by qualified nursing staff to satisfy the on-going professional development requirement of the Nursing and Midwifery Council: the eating July being
Sent To
- Care Quality Commission
Response Status
Linked responses
0 of 3
56-Day Deadline
28 Nov 2014
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 29ih July 2013 commenced an investigation into the death of Dorothy Mavis Clarkson, aged 78. The investigation concluded at the end of the inquest on 10' September 2014. The conclusion of inquest was that the cause of death was 1a Respiratory arrest due to 1b Inhalation of food with significant contributory factors at 2 Ischaemic heart disease, valvular heart disease and previous intracerebral haemorrhage: The conclusion in Box 4 was that Dorothy Mavis Clarkson died an accidental death _ contributed to by neglect:
Circumstances of the Death
DMC choked on a large piece of meat while her meal at Longton Nursing and Residential Home on the 25th July 2013 at approximately 1255hrs and became unresponsive. Initial attempts at resuscitation by staff at the home were unsuccessful, but paramedics who arrived shortly after were able to clear her airway and re-establish circulation. She was taken to Royal Preston Hospital where her condition deteriorated and she died on the 27th
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.