Woman tragically died after choking on Nutella and toast
Tina had been found unresponsive by a member of staff, who had left her alone briefly to get the phone while she was eating. Despite being placed on life support, she later died and her death was recorded as hypoxic brain injury, cardiac arrest, and choking on food.
Tina was described as 'a sociable funny person' who was close to her sisters, liked listening to music, and eating chocolate. She was diagnosed with cerebral palsy as an infant, had difficulty with her speech, and as an adult had no teeth or dentures.
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She had a number of health issues including mobility and breathing problems, incontinence, and was classed as morbidly clinically obese. A report into her death said she 'had choking risks associated with eating too fast, not chewing sufficiently, and having too much food in her mouth at once.'
Tina's case is one of two adult safeguarding reviews included in an annual update for Wirral councillors at an adult social care and public health committee meeting on July 15. Tina was initially cared for by her family but was later put into care under Wirral Council.
The report said she did not like to be identified by her disability and did not like it if her support staff would discuss her weight or attempt to control her eating of chocolate. The review said she would throw herself on the floor or attempt to swallow batteries, latex gloves, and plastic items and could on occasion be 'verbally abusive and sometimes aggressive.'
In November 2017, Tina had to move as her permanent accommodation was being upgraded. An emergency placement at a care home broke down and she became unhappy, prompting her to be moved three times on November 17.
Following her death, it was deemed the circumstances around her death and the number of agencies involved meant 'there was reason to pursue further enquiries about potential organisational neglect that might have contributed to her early death.'
On November 19, Tina asked for a roast dinner, dessert, and chocolate buttons as well as toast and Nutella. Notes said Tina was given 'lightly toasted bread cut into small pieces.'
After Tina was found choking and needing emergency CPR, she was later taken to Whiston Hospital where she died at 5.30am on November 20. Tina's assessment said she needed supervision when eating to avoid any choking risk.
A number of issues with the support provided was highlighted in the review and seven recommendations were made as a result. However some good areas of practice around communication, engagement with Tina and her family over her care, as well as support for community activities and the services involved were thanked for their willingness to improve.
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