Coroner’s warning after sandwich tragedy

Reporter: BEATRIZ AYALA
Date published: 09 September 2010


AN OLDHAM coroner has emphasised the need for rigorous patient assessment in care homes after a multiple sclerosis sufferer choked to death on a sandwich.

June Lynch (53) was diagnosed with MS aged 41 and moved to Chadderton Total Care Unit in 2000. Her mobility and speech continued to deteriorate.

Her daughter, Charlotte Edgar (23), from Norfolk, said her mother was almost bedbound and had to be fed by staff — but she could eat if food was cut into small pieces.

An inquest held at Oldham Magistrates Court yesterday heard how in September 2009, a staff member fed Mrs Lynch three-quarters of a ham sandwich when she noticed she “didn’t look right” and called for help.

A registered nurse arrived in seconds and felt the piece of food and tried to relax her to clear the airway. Emergency services arrived and took Mrs Lynch to the Royal Oldham Hospital, where she was pronounced dead. A pathologist found a “big chunk of food”, was blocking her larynx, too deep to reach by hand.

The court was told MS sufferers have impaired reflex responses and are incapable of coughing food out.

Cause of death was asphyxia due to choking with food due to multiple sclerosis.

Oldham coroner Simon Nelson raised concerns about the unit’s review of Mrs Lynch’s dietary requirements.

Though MS patients with coughing episodes or recurring chest infections were referred for a swallowing assessment, Mrs Lynch had neither. All residents had care plans stating how they had their food.

Mr Nelson said he was satisfied with Mrs Lynch’s care but emphasised the need for rigorous assessment of individual needs concerning dietary requirements.


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