Care home resident who choked to death on food 'should have been supervised'

The death of a care home resident who choked on her breakfast could have been avoided if she had been supervised, an inquiry has found.

Anne Amos was found unresponsive at Pine Villa Nursing Home in Loanhead in September 2021 after being left to eat alone in her room.

The 72-year-old, who had been diagnosed with frontotemporal dementia seven years earlier, had been admitted to the care home in August 2021.

Mrs Amos was noted to be non-verbal due to the progression of her condition and required close supervision when eating, but could sometimes feed herself.

On the day of her death, she was given tea and toast to eat in her room unsupervised. She was found unresponsive on her chair by a member of staff and later pronounced dead.

The cause of death was found to be choking on food and Alzheimer’s disease.

A Fatal Accident Inquiry into the “much-loved” wife and mother’s death found that the supervision of Mrs Amos while she was eating could have avoided her death.

Care assistants on duty the day of Mrs Amos’ death told the inquiry that they had never seen her eating and drinking plan, which identified the need for “close supervision”.

Sheriff Walls found that there was no adequate system to share important information about residents’ care needs with staff, and in particular, the identified requirement for Mrs Amos to be supervised while eating.

He added: “Pine Villa had determined that Mrs Amos should be supervised but failed to ensure that this was done.”

The owners of Pine Villa Nursing Home have since introduced a digital system, with each staff member given a handheld device which contains key information on each resident.

The sheriff also recommended that pre-admission forms about the resident’s care needs contain a series of questions highlighting the presence or potential risk of dysphagia or choking, that a choking policy be put in place and that staff training be given in relation to the policy.

Sheriff Walls shared his condolences with the family and thanked them for the dignified way they conducted themselves throughout the proceedings.