Death of woman who choked on chicken at Harleston secure hospital ruled an accident
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The death of a woman who choked on a piece of chicken at a Harleston secure hospital has been ruled an accident following a three-day jury inquest.
Theresa Barrett, 45, died on September 23 last year at Richmond House, an eight-bed locked community rehabilitation hospital where she was sectioned under the mental health act.
Miss Barrett - who suffered with paranoid schizophrenia, learning disabilities and a personality disorder - had been at the hospital since 2013.
At the time of her death, the unit was operated by Partnerships in Care, a company described as 'a trusted partner of the NHS', but is now run by the Priory Group following a merger in December.
The jury had heard Miss Barrett had eaten a piece of chicken brought into the hospital by another patient, who had been out for the morning.
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She had taken the chicken away on a plate towards the dining room, but staff members told of how another patient had shouted 'she's choking' and they found Miss Barrett pointing at her throat and chest, unable to speak.
Various members of staff attempted to help Miss Barrett by administering back slaps, and abdominal thrusts.
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And when she collapsed paramedics were called and CPR was given, but she lost conscious and the chicken could not be dislodged by staff, or paramedics.
It was finally removed by Dr David Potter, from the East Anglian Air Ambulance, but despite attempts to resuscitate Miss Barrett, she was pronounced dead at 1.56pm.
In a post-mortem examination, Dr James Sington gave the medical cause of death as choking on food.
Summing up the evidence, senior coroner Jacqueline Lake said: 'We heard evidence from a number of members of staff at Richmond House and Theresa was generally described at lovely, bubbly and happy but she could be quite demanding.
'We heard at Richmond House patients would prepare their own meals with help from staff in the kitchen. The evening meal would be eaten together to encourage social etiquette and enable patients to be observed.
'Breakfast and lunch were taken on an informal basis and snacks were also available to residents. We heard at these times there would usually be staff around in communal areas.'
Miss Barrett's consultant psychiatrist Dr Ignatius Gunaratna told the court that long term hospitalisation could cause rapid eating.
'And we heard she was known to eat rapidly from various members of staff,' Mrs Lake said.
'There were references in Theresa's record to her eating. In 2014 reference was made to her gagging while eating and walking around and dws to eat her meals too quickly and being told to slow down.'
A document was prepared in 2014 in relation to all residents where it was noted Miss Barrett would gag when eating too fast.
On the document, boxes had been ticked indicating she had problems with swallowing food and problems with chewing food.
In November 2015 there was a record that Miss Barrett ate well and just needed telling to slow down when she was drinking too fast.
But on February 18 2016, healthcare worker Billy Eaton was eating with Miss Barrett when she choked on a piece of broccoli. However, he was able to dislodge this after giving her back slaps and then abdominal thrusts.
Mrs Lake said: 'He reported this to a senior nurse and a note was made in the daily report.'
In the report it said Miss Barrett had been eating in a hasty manner but the situation was 'well managed'.
Mrs Lake added: 'The nurse made a further note in the care notes that the healthcare worker was to complete the incident report and this was not completed.
'Had it been in place Sharon Drake (ward manager) said in evidence Theresa would have been reviewed by a GP and a multidisciplinary team and the outcome would have guided any further investigation which may have altered her care plan.'
Two staff members were told of the incident verbally at handover, but three other members of staff - including Dr Gunaratna and Ms Drake - did not know about the incident until after her death.
Mrs Lake said she felt changes had been made to prevent further deaths.
A hospital spokesman said: 'Ms Barrett was a kind, sociable and friendly person and our sympathies are with her family. We take the safety and wellbeing of all of our patients extremely seriously and are pleased that the coroner has agreed lessons have been learned following this accident. We regularly review our practices and procedures to manage choking risks and will consider the inquest findings carefully.'
When asked what changes had been made to prevent further deaths, the spokesman was unable to comment.