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Avoidable death: coroner warns about inadequate nurse training

A nursing home nurse who performed ‘ineffective’ cardiopulmonary resuscitation (CPR) on a woman with swallowing difficulties who was choking to death had been insufficiently trained – and was the only staff member to have valid life-support training. A coroner’s report pointed to lack of essential information-sharing at Mandeville Grange Nursing Home in Buckinghamshire about Sheila Nicholls’ swallowing difficulties, resulting in her being served toast for breakfast. Relatives had informed the home of the choking risk but this information was not passed to staff caring for her. The coroner said neglect had been a factor in Ms Nicholl’s death. He was critical of two internal investigations the nursing home subsequently conducted and warned of future risk of fatality if staff are not given adequate training.
CPR training for nurses: nurse kneels over woman lying on the floor, placing her hands on her shoulders

Nurse who performed ‘ineffective’ CPR on woman who died from choking was inadequately trained and front-line staff were not alerted to patient’s swallowing risk

CPR training for nurses: nurse kneels over woman lying on the floor, placing her hands on her shoulders
The nursing home’s staff did not have adequate emergency simulation training and the nurse who performed CPR was alone in having any valid life-support training Picture: iStock

A nurse who performed ‘ineffective’ cardiopulmonary resuscitation (CPR) on a nursing home resident who choked to death on toast had insufficient training, a coroner found.

Sheila Nicholls died one day after entering respite care at Mandeville Grange Nursing Home in Aylesbury, Buckinghamshire, in November 2023. Information relatives had given staff about her swallowing problems was either omitted or not shared with those looking after her, assistant coroner Michael Walsh said in a prevention of deaths report. He said neglect had contributed to Ms Nicholls’ death.

Nursing home neglect: inadequate CPR training and poor communication about choking risk

The report described deficiencies in nurse education, saying the nurse who carried out CPR on Ms Nicholls did so ineffectively without being corrected. The nurse was the only staff member at the time to have valid life support training.

‘Deficiency in training and embedding that training, for all staff and for that nurse, creates a risk of death to residents, should future emergencies arise’

‘Whilst [the nurse] still works for Grange Mandeville Nursing Home, it is unclear how they will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient,’ the report states.

‘The deficiency in training and embedding that training, for all staff and for that specific nurse, creates a risk of death to residents, should future emergencies arise.’

‘Important information about Sheila’s swallowing difficulties went unrecorded and was not shared between staff’

There was also evidence of a failure to perform simulated emergency drills at the nursing home, and some staff were unaware their training had expired.

Family alerted nursing home to woman’s swallowing difficulties

Ms Nicholls became a resident at the nursing home on 18 November 2023 and died a day later after choking on toast. She was 80.

‘Her family warned the nursing home of Sheila’s swallowing difficulties and a need for monitoring whilst eating and to avoid certain foods, but important information went unrecorded and was not shared between staff, resulting in Sheila being provided with food she should not have been given and/or should have been prepared differently,’ Mr Walsh noted.

‘Sheila subsequently choked on toast, suffering hypoxia that led to a cardiac arrest and what was an otherwise avoidable death. Neglect contributed to the cause of death.’

Nursing home’s investigations of woman’s death were inadequate

Mr Walsh said two internal investigations by the home failed adequately to consider ‘significant matters’ and were undertaken by staff not trained in investigate adverse incidents.

Mandeville Grange Nursing Home told the inquest it would appoint external investigators in the event of future unexpected or unnatural deaths. It has until 5 March to respond to the report.

A spokesperson for Mandeville Grange Nursing Home told Nursing Standard: ‘We acknowledge the coroner’s findings, and our thoughts are with Ms Nicholls’ family, to whom we extend our deepest sympathies.

‘Following the incident in 2023, a full internal investigation was conducted and immediate steps taken to further improve policies and training. The welfare of our residents is our utmost priority, and we continue to work closely with independent experts, the Care Quality Commission and local authorities to ensure that the highest standards of care are met and upheld.’


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