A great-grandmother died after choking on a piece of sausage which a coroner ruled was ‘not suitable’ for her to eat.
Blackburn Coroners Court was told that Oswaldtwistle-born Nora Gilmartin, 84, died after choking on an ‘inch-long’ piece of sausage that had become lodged in her throat – despite having had assessments that placed her on a ‘soft food diet’.
She was a resident at Addison Court care home in Accrington when she choked on January 27 and was taken to Royal Blackburn Hospital, where she died two days later on January 29, the inquest was told.
Coroner Rachel Galloway ruled that her death was accidental, but that she should not have been given the sausage to eat – as it was ‘not suitable’ for her in view of her health problems and dietary assessments.
On January 27 Mrs Gilmartin had been eating sausage for lunch in the dining room of Addison Court with her husband Jim, who was also a resident at the home.
Care staff gave evidence that the sausage was ‘very soft’ and had been oven cooked.
Care assistant Louise Nightingale attempted to feed Mrs Gilmartin a pudding, and helped her drink a glass of water before she realising that she was choking, the hearing was told.
She said: “We noticed she didn’t look quite right her lips seem to be going blueish and the colour was draining from her face.
“I got down on my knees holding Nora’s hands to try and encourage her to cough and she seemed to take a big gasp and colour started to come back but they were laboured breaths.
“A piece of sausage came out.”
The alarm was raised and Mrs Gilmartin was taken to Royal Blackburn Hospital in an ambulance, where she underwent surgery to remove the food that had become lodged in her pharynx.
Her daughter Janet Francis told the inquest that she was shown the piece of food afterwards, which measured ‘slightly over an inch’.
She said: “It had skin on. I would have said it was tough meat, only because of the quality of the sausage.”
In a statement read to the inquest, consultant doctor Stephen Gilligan said Mrs Gilmartin never gained consciousness and was placed on sedative and palliative drugs.
The cause of death was recorded as cardio respiratory failure following cardiac arrest after choking on food.
Resident had been placed on 'soft food' diet
Mrs Gilmartin, who suffered with Parkinson’s Disease and dementia, had undergone a speech and language therapy (SALT) assessment by therapist Lyndsey Fraser in August 2016 who placed on her on a ‘soft food diet’ and advised that tough foods, such as meat, should be avoided, the inquest heard.
However the advice was not followed and there was an incident in December 2016 where she was found to be choking on ‘three large pieces of meat’, the hearing was told.
Ms Fraser subsequently conducted another SALT assessment which emphasised that tough foods – such as meat – should be shredded, chopped small or pureed if they could not be chewed.
She told the hearing: “I was asked to come out again because Nora was still having difficulties with a normal diet. She was supposed to be on a soft options diet.
“But when I went out I was told she was struggling to chew meat in large pieces, but my previous advice was to avoid meat in large pieces.”
A further ‘food incident’ later occurred on January 6 where food had to be emptied from Mrs Gilmartin’s mouth, and staff at Addison Court recommended that she be placed on a ‘pureed’ diet – but this had not been implemented by January 27 the coroner heard.
Sarah Perez, operations director for Addison Court, said: “It is a concern if you’re given advice from an external professional the expectation is that it should be followed.
“We certainly do need to learn on that front through training and supervision. All staff need to reflect on the circumstances of this, especially those who were directly involved.”
In her conclusion, assistant coroner Rachel Galloway said: “I found that the piece of sausage became lodged in the airway of Nora Gilmartin and this ultimately led to her death.
"I do not find it was suitable to give to Nora Gilmartin, who was on a soft diet.
“I find the sausage was not shredded, I find that it was not chopped into small enough pieces for this particular patient. I also find it was too hard for her.
"It may not have been as big as one inch but it was tough and too large for Nora Gilmartin and should not have been offered to her.
“I find that the future risk in this particular incident has been addressed, as it has caused me some concern, but I believe staff training is the only way for that to be addressed.”