Hospital failings led to death of ‘wonderful’ 68 year old who choked to death on food
PUBLISHED: 06:00 22 September 2018 | UPDATED: 09:59 24 September 2018
©2018 INS News Desk/INS News Agency Ltd
The daughter of a severely schizophrenic woman who died choking on chocolate cake in the care of a Reading psychiatric hospital has spoken of her grief at the death of her “loving, supportive and intelligent” mother.
“She loved nothing more than sitting on the benches in Broad Street with a can of coke just watching the world go by.”
This is how 42-year-old Christie Dyball described her late mother, Anne Roberts.
Having grown up in foster care from the age of six, Mrs Dyball has few photographs of Miss Roberts, who died almost a year ago while in the care of a Reading psychiatric hospital.
But instead she has placed a bench in her own front garden, in a quiet street in Cromer.
She said: “The sun comes round in the evenings and we can just sit there and remember her, and how supportive and misunderstood she was.”
Miss Roberts, a retired cleaner, was diagnosed with schizophrenia when her daughter was a child.
But despite coping with her condition for more than 35 years, she had a stable and independent life, and a happy relationship with her only daughter and her two grandchildren; calling herself ‘Nanny’ to Mrs Dyball’s two girls.
After a fall in 2015 she moved into sheltered housing, but struggled to manage the change.
Mrs Dyball said: “She went downhill really severely in 2017.”
Miss Roberts was on medication for conditions including schizophrenia, COPD and an enlarged heart and had previously always taken her prescriptions.
But her daughter said: “I don’t think she was taking her psychiatric medication or the physical medication was having an adverse effect because she went downhill quite rapidly.
“We went to see her for her birthday in August 2017, with my daughters and had a terrible weekend because she was beginning a psychosis.
“She was acting very strange and calling me a bad person.
“Her tablets were all open in a mess at the bottom of her trolley - all the different pills.”
On the way home, Mrs Dyball was contacted by the Royal Berkshire Hospital with the news Miss Roberts had overdosed.
She was admitted to Prospect Park Hospital (PPH), in Tilehurst, on August 26, and sectioned under the Mental Health Act.
Miss Roberts suffered a choking incident on September 22, and was resuscitated by staff at PPH.
She remained at the hospital and a speech and language therapist (SALT) recommended she be placed on a soft diet.
But just six days later, on September 28, she choked on a piece of chocolate cake, solid food she was not supposed to have been given, and this time staff were unable to resuscitate her.
An inquest into Miss Roberts’ death found that guidelines in relation to her dietary needs were “inadequately passed on” to staff directly involved in her care, and that staff actions were inadequate to minimise her risk of choking, despite the previous incident.
The inquest found Miss Roberts was at “high risk of choking”.
The narrative conclusion, returned in just two-and-a-half hours, found staff “observed [her] in an unsuitable eating position for a number of minutes”.
Two care assistants gave Miss Roberts her lunch in her room, as she was under two-to-one care.
Her furniture had been withdrawn for her own safety, and she was fed on her mattress.
Her daughter believes her position, reclining on her left side, meant the staff supervising her, one from outside the room, did not immediately notice her choking.
Mrs Dyball said: “We don’t know for certain how long she was eating that food for before they noticed she was choking.”
The inquest heard from the two care assistants that it was thought to have been around two minutes.
Speaking to this newspaper, Mrs Dyball paid tribute to her mother.
She said: “She was very intelligent. She passed her 11+ and went to grammar school, but she had a very unhappy childhood.
“She wasn’t particularly loved and left home at the age of 16.
“She lived in the same council house, and enjoyed shopping and watching television. She doted on my two daughters, Lily and Rachel, and was a wonderful, supportive grandmother.
“Despite being brought up in foster care from the age of six, I always saw her regularly.
“She never missed a visit and we maintained contact after the girls were born.
“She had beautiful handwriting. I found this card she wrote to my daughter.
“She really was a bright lady but she just had an awful lot of bad luck in her life.”
Mrs Dyball added: “This year has been hard. We haven’t really had a holiday or done a great deal.
“I’m going to get a simple little bronze plaque for the bench, just to say ‘in memory of a loving mum and grandmother’.”
The inquest’s findings:
The inquest into Miss Roberts’ death concluded failings in her care caused or contributed to her death.
After a four-day inquest at Reading Town Hall, a jury said the speech and language therapist’s (SALT) guidelines in relation to Anne’s diet were not adequately passed on to staff on her ward and handover notes were inadequately detailed.
They returned a narrative conclusion on Friday, September 14, 2018, which found the medical cause of her death to be choking.
The conclusion stated it was appropriate to give Miss Roberts lunch in her room, “due to the high risk of harm to self, patients, and staff”.
But they found her food was unsuitable for her needs and staff didn’t do enough to prevent her choking.
These failings caused or contributed to her death.
Assistant coroner for Berkshire, Ravi Sidhu, said he intended to issue a Prevention of Future Deaths (PFD) report into Mrs Roberts’ death in due course.
The hospital’s response:
The Berkshire Healthcare NHS Foundation Trust operates Prospect Park Hospital.
Helen Mackenzie, director of nursing and governance, said: “I would like to express our sadness and deepest condolences to the family of Anne Roberts following her tragic death in September 2017.
“As the organisation responsible for Anne’s care, we cooperated fully with the Coroner’s inquiry and accept the jury’s findings in this case.
“Immediately following Anne’s death, we made changes to areas of practice we identified as requiring improvement.
“We also conducted an investigation which highlighted additional areas of learning, and further work to strengthen our systems and processes was fully implemented prior to the inquest.
“This has included increased investment in speech and language therapy staff and resources, and the delivery of specialist training to our medical and nursing staff.
“We are continuing to monitor our procedures to make sure we provide the best possible care for our patients now and in the future.”