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Safeguarding Adults Review Mrs E (March 2021)

Mrs E was a 82 year old woman with a diagnosis of dementia who lived in a care home. Mrs E condition was worsening and so was given one to one care. Mrs E was left unattended and started to choke, however there was confusion between staff and the nurse in charge as to whether Mrs E was choking or struggling to breath. The ambulance service managed to remove a bolus of food from Mrs E airways however on admittance to hospital she was found to have irreversible brain damage and passed away. The coroner held an inquest into the death of Mrs E and concluded an outcome of accidental death contributed to by neglect.

SAR Mrs E FINAL Executive Summary Mrs E FINAL

Action Plan April 2021 Mrs E (002)

7 minute learning Mrs E