Nursing home admits negligence leading to pensioner’s death from choking

A pensioner choked to death after being left alone in a nursing home to eat despite a clear mandate that she should be fully supervised during mealtimes.

And nursing home staff failed to carry out CPR on 85-year-old Alice Cairns despite family members saying the DNR wishes in her Respect Form had not been provided by them nor confirmed by them.

Now the family of Alice, who died at Southcrest Nursing Home, Redditch in May last year, want to raise awareness about the home’s failings in care and supervision.

Granddaughter Joanne Agnew, of Glasgow, said: “Due to a breach of duty by the nursing home in three crucial areas, my grandmother was subject to unnecessary pain and suffering, which ultimately resulted in her death.

“We urge other families to be vigilant: care orders are being put in place without the knowledge of close family. Care homes must do better.”

Leading Midlands law firm FBC Manby Bowdler has now secured an admission of negligence and liability from the nursing home, who settled the claim for the sum of £10,988.

Alice Cairns moved to Southcrest Care Home in August 2019 and suffered with dementia and fragility. Twice a year, choking risk assessments were carried out and since March 2022 Alice was confirmed as needing full supervision and assistance throughout mealtimes.

On the day of her death, at 4.14pm, two carers sat Alice upright in bed and a plate of sandwiches cut into bite size pieces was placed on her overbed table. A witness statement from one of the carers said Alice began to feed herself, and the carer left the room for a short time. When she returned, the sandwiches were almost finished, and she helped Alice with her dessert and drink.

The witness said: “During her meal she did not cough or appear to struggle in any way.”

Shortly after 5.30pm, the witness said she saw Alice sitting upright raising and dropping her shoulders slowly and appeared red in the face. She called for help from a colleague, but Alice’s condition continued to deteriorate and at 5.42pm an ambulance was called.

No attempt at cardio pulmonary resuscitation was made by staff because a Respect Form was in place, which also stated that she was only to be admitted to hospital in exceptional circumstances for acute reversible conditions.

When paramedics arrived, they found that Alice’s airway was blocked by a large amount of bread. Multiple procedures were attempted to no avail and a second ambulance crew was called and chest compressions were started.

Jordan Higgs, in his Letter of Notification to the care home, said: “It is of note that the witness statement of paramedic Jonathan Charles Eades states ‘A staff member informed the crew that the patient had been given a sandwich to eat at approximately 17.15 and was left to eat it on her own, in her room, which staff stated was normal for her’.

“While a Respect Form was provided confirming resuscitation was not to be performed, it was decided by paramedics to continue with the resuscitation events because the cardiac arrest was, in their view, due to an extraneous event, likely choking, and not due to a medical event and prior to this event the patient had been behaving as normal and had not complained of illness.”

Over the next few hours, Alice was subject to multiple procedures, including use of suction devises, ongoing chest compressions, an oropharyngeal airway, manual ventilation and an intraosseous cannulation – a needle directly into the bone to administer drugs.

Alice was blue lighted to hospital and made comfortable but subsequently died at 7.51pm.

An inquest into Alice’s death was held on 10 February 2025, during which several discrepancies were identified in the statements of care home staff, namely whether or not Alice was left alone while eating despite a mandate being in place saying she should always be fully supervised.

The Coroner concluded that Alice died from an unwitnessed episode of choking due to a brief moment of suboptimal supervision and that in those brief moments the care fell short of the supervision that she should have had.

Lawyers maintain that the three breaches of duty by the nursing home were:

·     That Alice’s family should have been consulted on the use of a Respect Form, and that they would have confirmed that it was not their wish; if that had been the case, as soon as Alice was seen to be choking and in distress, CPR would have been started immediately

·     Leaving Alice unsupervised during mealtime; had someone been with her at all times she would not have eaten her food in such a manner as to cause an airway obstruction

·     Recognising Alice’s choking as a non-natural event; Alice should have received immediate CPR on recognition that she was in distress and needed urgent medical intervention

Jordan Higgs concluded: “But for these three breaches of duty, Alice would have avoided the pain, suffering and loss of amenity endured during her unwitnessed choking and subsequent cardiac arrent. In addition, her death could have been avoided.”

Ends

Editors notes

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