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recurance

Ivy Dixon

10 Apr 2025 · Coroner Ian Potter · Inner North London

The coroner's concerns

  1. 1. choking leading to cardiac arrest

    “[the deceased] choked on food causing cardiac arrest while being fed by staff in her room at Acorn Lodge Care Home on 6 October 2024. Carers called an ambulance but did not perform CPR when Mrs [name redacted] became unresponsive prior to an ambulance arriving.”
  2. 2. miscommunication about feeding status

    “Care staff told the paramedics that Mrs [name redacted] had not been fed that evening. This was not true. This led paramedics to conclude that Mrs [name redacted] cardiac arrest did not have a reversible cause.”
  3. 3. failure to initiate CPR despite reversible cause

    “staff from the Care Home were not undertaking CPR. The DNACPR would not have applied in this case, because choking is a potentially reversible cause of cardiac arrest, which the Care Home's manager confirmed in her evidence.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Ivy Dixon · Recurance