Tom Gent represents care home at Manchester inquestPark Square Barristers
The case involved the death of a 77-year-old lady who had died at a home in Manchester in October 2018, having stopped breathing whilst not being observed in her bed. She had been discharged from hospital, where she had been treated for aspiration pneumonia and dysphagia (difficulty swallowing), in August of the same year. The post mortem had discovered food material within her airways. The medical cause of death was offered as:
- (a) inhalation of gastric contents
- myocardial fibrosis and chronic obstructive airways disease
As well as hearing evidence about events during the hours leading up to her death, the inquiry considered evidence relating to her care plan, with particular focus on the risk assessments in relation to her feeding. The Coroner found that the plans that were in place were entirely appropriate and reasonable. He went on to express the view that in his view no liability rested with any individual or institution. His conclusion (as noted in box 4 of the record) was “misadventure”, meaning that the death was the unintended consequence of a deliberate act.