Craig Spiby
10 Dec 2024 · Coroner Timothy Brennand · Manchester West
The coroner's concerns
1. choking on food and liquids at mealtimes
“The deceased suffered from Phelan McDermid Syndrome - a rare and debilitating chromosomal disorder, that amongst other symptoms, rendered him susceptible to choking on food and liquids at mealtimes”
2. lack of supervision at mealtimes
“The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be 'supervised'”
3. ambiguous definitions of monitoring and supervising
“Managers gave evidence that their definition of 'monitoring' and 'supervising' was an expectation that the deceased would be kept in 'line of sight' at all times”
4. inadequate supervision due to misinterpretation of monitoring
“Care workers gave evidence that they were expected only to 'monitor' the deceased - which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within ear”
5. insufficient first aid training for choking emergencies
“improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial”
6. lack of training to prevent confirmation bias in high-risk service users
“An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events”