Stephen Dulling, from Thirsk, in North Yorkshire, was being treated at York District Hospital in September of last year when he choked on his breakfast, and went into cardiac arrest.
Two days later he died in hospital, and a post-mortem report found that the 69-year-old had toast in his airways, and gastric contents in his lungs, known as aspiration pneumonia.
Now, a coroner has criticised two trusts involved in his care, Tees, Esk & Wear Valley Trust (TEWV) and York & Scarborough Teaching Hospitals Trust (YSTH) for feeding him an inappropriate diet, and offering limited care whilst he was struggling.
Coroner for North Yorkshire, Catherine Cundy filed a Prevention of Future Death report, which will make both trusts take action to ensure that deaths cannot occur in similar circumstances.
The York trust said improvements will be made, and an action plan written up, to ensure safety standards are met in future.
In the lead up to Mr Dulling’s hospitalisation in August 2023, his wife had been in touch with the crisis team at TEWV. She told them that her husband, who had Parkinson’s and dementia symptoms, was angry and distressed and she needed help.
During previous assessments with the crisis team, he was deemed to present a risk of harm to himself and others – but the team did not give Mrs Dulling any practical advice, or suggest taking him to acute hospital.
Instead, she was told to call the police if she feared for her safety, leaving her “frustrated” at their lack of help.
In her report, the coroner wrote: “My concern is that a repetition of such a limited response could present a risk of future deaths to others.”
Days later, when Mr Dulling was on the acute ward run by YSTH, the coroner noted a “number of omission and lapses in care”.
His nurses failed to ask his family if he had nutritional needs or dietary requirements, even though he lacked the capacity to know what was best for him.
As a result, he was put onto a regular diet, no food chart was implemented, and there was no assessment of Mr Dulling’s refusal of intravenous fluids.
When Mr Dulling began to choke on his toast on the morning of September 2, 2023, there was a “delayed response” by a staff nurse.
Later at York District, staff failed to do a debrief within three days of the incident, and the undertaking of a patient safety review was delayed.
Coroner Ms Cundy said that this delay resulted in “important gaps” in the evidence supplied to a clinical reviewer, and to the inquest.
The coroner said: “My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.”
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A spokesperson for York and Scarborough Teaching Hospitals NHS Foundation Trust, said: “The Trust would like to convey sincere condolences to Mr Dulling’s family.
“We recognise and share the concerns raised by the HM Coroner. Following the conclusion of the inquest we appreciate that the coroner wishes for us to take further steps, and we fully take that on board.
“We will be setting out our action plan and implementation timetable to meet the coroner’s deadline. The Trust takes patient safety seriously and endeavours to ensure lessons are learned.”
