Prevention of Future Deaths reports · 2023

John Lee

Regulation 28 report to prevent future deaths, reference 2023-0505, written 6 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Dec 2023
Reference2023-0505
DeceasedJohn Lee
CoronerAnna Crawford
Coroner areaSurrey
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedSurrey and Sussex Healthcare NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT 
IN THE MATTER OF: 

__________________________________________________________ 

The Inquest Touching the Death of John LEE   
A Regulation 28 Report – Action to Prevent Future Deaths 
__________________________________________________________ 

1  THIS REPORT IS BEING SENT TO: 

Angela Stevenson  
Chief Executive  
Surrey and Sussex Healthcare NHS Trust  
Trust Headquarters  
East Surrey Hospital 
Canada Avenue 
Redhill 
RH1 5RH 

2  CORONER 

Miss Anna Crawford, H.M. Assistant Coroner for Surrey 

3  CORONER’S LEGAL POWERS 

I make this report under paragraph 7(1) of Schedule 5 to The Coroners 
and Justice Act 2009. 

4 

INQUEST 

An inquest into Mr Lee’s death was opened on 8 December 2022.  The 
inquest was resumed and concluded on 20 November 2023.    

The medical cause of Mr Lee’s death was: 

1a. Choking 

2. Dementia  

With respect to where, when and how Mr Lee came by his death it was 
recorded at Box 3 of the Record of Inquest as follows: 

 
 
 
 
 
 
 
 
 
 
 
 Mr Lee was an 83 year old man with dementia who lived in a care home. 
On 17 August 2022 Mr Lee was admitted to East Surrey Hospital 
following a fall. By 31 August 2022 Mr Lee was medically fit for 
discharge, however, he remained in hospital while efforts were made to 
find him a more suitable care home.  Whilst he was in hospital Mr Lee 
was found to have a newly impaired swallow, the primary cause of which 
was thought to be his worsening dementia, which placed him at risk of 
choking and aspiration.  
On 1 September 2022 Mr Lee was assessed by the Speech and Language 
Team (SALT Team) as being suitable for normal consistency foods, 
however, a number of recommendations were put in place to minimise 
the risk of choking and aspiration. These included to monitor him closely 
whilst he was eating and to check his mouth after eating to locate and 
remove any food debris. This recommendation was made because 
dementia patients are known to be at risk of holding food in their mouths 
and forgetting to chew or swallow it, which presents a risk of subsequent 
choking.  
On 2 September 2022 hospital staff did not complete Mr Lee’s food chart 
from mid-morning onwards and, as such, it has not been possible to 
establish what and when Mr Lee ate on 2 September 2022, save for the fact 
that he ate breakfast. However, Mr Lee had food residue in his stomach at 
post-mortem, which is consistent with him having a eaten a further meal 
or meals after breakfast.  
Overnight on 2-3 September 2022 Mr Lee was confused and agitated and 
repeatedly tried to get out bed. He remained agitated until approximately 
3am when he settled down and went to sleep.  
At approximately 5.30am he was found unresponsive and his death was 
formally declared by a doctor later that morning on 3 September 2022.  
A post-mortem examination was conducted which found that Mr Lee had 
died due to choking on a piece of food.  
It has not been possible to establish precisely when on 2 September 2022 
Mr Lee ate the food that he subsequently choked on. However, having 
eaten it, he retained it in his mouth for a period of time before 
subsequently choking on it.  
Had Mr Lee been closely monitored and provided with effective 
mouthcare on each occasion that he ate on 2 September 2022, in 
accordance with the SALT recommendations which were in place for him, 
he would not have choked and he would not have died 

The inquest concluded with a short form conclusion of ‘Accidental Death’ 
together with the following short narrative conclusion: 

 
 
 Mr Lee was not closely monitored or provided with effective mouth care 
whilst eating on 2 September 2022. Had he been closely monitored, and 
provided with effective mouth care thereafter, he would not have choked 
and died on 3 September 2022. 

5  CIRCUMSTANCES OF THE DEATH 

During the course of the inquest the court heard evidence from 
of the hospital’s SALT team that it was standard practice for dementia 
patients to have their mouths checked after eating, in order to locate and 
remove any food debris.  This is because dementia patients are known to 
be at risk of holding food in their mouths and forgetting to chew or 
swallow it, which presents a risk of subsequent choking.   

However, Mr Lee’s mouth care records indicate that he had only received 
mouth care once daily during the entirety of his hospital stay.   

The Court is therefore concerned that there is a risk that dementia patients 
are not receiving mouth care on each occasion that they eat and that this 
presents a risk of future deaths.  

 
 
 
 
 
 
 6  CORONER’S CONCERNS 

The MATTER OF CONCERN is: 

The Court is concerned that there is a risk that dementia patients at the 
Trust are not receiving mouth care on each occasion that they eat and this 
presents a risk of future deaths.  

7  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe that the people listed in paragraph one above have the power to 
take such action.  

8  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of its date; I 
may extend that period on request. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for such action. Otherwise, you must 
explain why no action is proposed. 

9  COPIES 

I have sent a copy of this report to the following: 

1.  Chief Coroner  
2.  Mr Lee’s family  

 
 
 
 
 
  
 10  Signed: 

ANNA CRAWFORD  

Anna Crawford 
H.M Assistant Coroner for Surrey 
Dated this 6th day of December 2023

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Surrey and Sussex Healthcare NHS Trust (PDF)
r.!1:1-1 
Surrey and  Sussex  Healthcare 
NHS  Trust 

Headquarters 
East Surrey Hospital 
·  Canada Avenue 
Redhill 
RH15RH 

09  February 2024 

Please reply to: 

. 

· Title:  Chief Medical Officer 

Ms Anna Crawford 
H M Assistant Coroner for Surrey 
Station Approach 
Woking 
GU22 7AP 

Dear Ms  Crawford 

Regulation 28  Report- response  by Surrey & Sussex Healthcare NHS  Trust 
Inquest touching  upon the death of John William  Lee (Date of Birth  07/03/193~) 

This  response  comprises  the  formal  response  of Surrey  &  Sussex  Healthcare  NHS 
Trust (the Trust),  pursuant to  section  7(2) to schedule  5 of the  Coroners  and  Justice 
Act 2009 and  Regulation 29 Coroners (Investigations) Regulations 2013, to the issues 
raised  in  the  Regulation  28  Report  to  Prevent  Future  Deaths,  dated  29  September 
2023,  made  subsequent  to  the  inquest  into  the  death  of  Mr  Nickols,  which  was 
concluded on  20  November 2023. 

The  Trust  was  given  until  31  January  2024  to  respond  to  the  coroner,  pursuant  to 
. Regulation  29(5)  Coroners  (Investigations)  Regulations 2013.  I am  very sorry for the 
delay in  providing this response to you,  it has been an  exceptionally busy period  in the 
Trust and  our focus has been  directed to our patients and  their safe care. 

We would  like to  start this  response  by offering  our sincere  condolences  to  Mr Lee's 
family for their loss. The Trust accepts fully the findings of HM .Coroner, and that there . 
was failure to follow the  SALT  recommendations to  closely  monitor Mr Lee whilst  he 
was eating and drinking, and to check his mouth after eating for items of food or debris. 
We are truly sorry that Mr Lee died as a result of choking on food that he had  retained 
in  his mouth, and we  accept that had the SALT recommendations been followed, then 
Mr Lee would  not have died when  he did. 

The  Prevention  of Future  Deaths  report  identifies the following  area  of concern,  and 
we  address  this  in  the  response,  with  details of the  actions that we  have  undertaken 

 
 
 
 
 
 
 and those that we  plan to undertake, along with the details of the improvement to date 
that have already resulted from  these actions in  the appended Action  Plan . 

The Court is  therefore  concerned  that there  is  a risk that dementia  patients  are 
not receiving  mouth  care  on  each occasion that they eat and  that this  presents 
a risk of future  deaths. 

,  Consultant Admiral  Nurse  for  Dementia  to  review  the  care 
I asked 
dementia  patients  receive  specifically  in  relation  to  mouth  care  when  eating  and  to 
include their dietary and  swallow assessments  from  the  time  of their admission.  The 
review  included  expertise  from 
Clinical  Lead  for  Speech  and  Language  Therapy  [SALT};  and 
Nurse Informatics Officer. 

,  Mouthcare  Lead; 

,  Chief 

As  a  result  of the  review,  the  Trust  identified  eight  actions  to  enhance  the  patient's 
care  pathway,  and  ensure  risks  are  identified  and  measures  put  in  place  ·to  help 
prevent and  safeguard  a dementia  patients'  risk  when  eating.  We intend  to  keep  the 
focus on  improving dementia patients care and the actions detailed below will achieve 
this . 

. 

To ensure  patients,  receive  harm  free  and  high  quality  nutritional  care,  it  is  vital  that 
those  patients  at  risk  are  identified  and  placed  on  the  correct  care  plan  in  a  timely 
manner.  This  will  be  achieved  through  the  effective  use  of  screening  tools  and 
enhancing  staff knowledge. 

The  Trust will  create  a  Food  Strategy  Nutrition  Steering  Group  which  will  advise  the 
Trust  on  all  aspects  of nutrition  from  food  provision  through  to  intravenous  nutrition 
support.  This  group  will  monitor  numbers  and  trends  in  incidents  and  ensure  action 
plans  are  followed  through;  it  will  seek  assurance  of  the  nutrition  and  hydration 
elements  of harm  free  care  within  the  Trust and  provide  assurance  to  the  Board  via 
the Quality Committee by the  Chair of Nutrition Steering  Group.  This will  ensure that 
the Trust's systems in  relation to both food  and  investigations are safe. 

A  strategy document will  also  be  created  in  the  coming  year which  sets  out  how the 
Trust will ensure that it provides safe,  high quality nutritional care for all,  over the next 
3 years. 

Yours sincerely 

Chief Medical Officer 
Surrey and  Sussex Healthcare NHS Trust. 

Enc.  Action  Plan 

2 

 
 
 Action  Plan  Lead 

 (Consultant 

Nurse Dementia) 

Implementation Ownership 
Oral Nutrition and 
Hydration Group 

Monitoring will occur via Clinical Effectiveness 
Committee and  progress will be reported to 
Quality Committee and  Safety and Quality Committee 

Action owner: 
(job  title) 

Deadline 
for Action: 

Expected Improvement/ 
Success Measures: 

AUDIT RESULTS / 
EVIDENCE 

No: 

1. 

2. 

Recommendation I 
Issue to be 
addressed: 

Initial assessment 
On  and  during the 
admission staff  must 
record  concerns 
regarding  swallowing 
difficulties from 
patient 
observations/report 
from  patient/family/ 
carers  and  make 
referral for full 
assessment by 
Speech and 
Language Therapy. 

Patient 
identification/visual 
cues 
Where a patient has 
been  assessed at risk 
from  aspiration  of 
food/fluid  due to 
swallowing difficulties 
associate with 
dysphagia  a clear 
plan  is available on 
how to  support the 
patient. 

Action(s) to be taken: 

Action 
Category 

Action 
(SMART) 

-

Preventative  Ensure where 

concerns regarding  a 
patient swallow is 
identified a referral  is 
made to hospital 
Speech and  language 
therapy service. 

-

Preventative  Feeding  plan  and 
swallow strategies 
are clearly displayed 
by bed side of patient 
assessed at being  at 
risk. 

New staff/ 
Agency/bank staff 
made aware during 
ward  induction  of 
patients with 
dysphagia swallowing 
needs 

Feb 2024 
Re-audit 
June 2024 

Spot audit of current 
inpatients with  dementia, 
has swallowing concerns 
been  highlighted,  has a 
referral to  Speech and 
Language been  made,  has 
patient been  assessed and 
recommendations made by 
SALT. 

Any swallowing concerns 
appropriately identified/ 
Appropriate referrals made 
from  ward,  Referral  picked  up 
and  seen  by  SALT in  a timely 

Feedback to the 
wards/clinical areas if any 
issues  or new learning 
identified and  using 

Feb 2024 
Re-audit 
June 2024 

Spot audit in  clinical areas 
to  ensure that patients 
identified at risk of 
swallowing due to  . 
dysphagia. That swallow 
plans are clearly visible in 
hand over document and 
on  patients' bed 

Clinical Audit and  quality 
improvement methodology to 
be  used to drive improvement 
until audit standards are met. 

Audit tool  used  and feedback 
to clinical area team  of 
concerns and  good  practice. 

3 

 
 
 3. 

To ensure that this is 
communicated and 
documented at ward 
handovers/ huddles. 
Mouth care matters 
on  Cerner 
Review mouthcare 
documentation on 
Cerner with the 
electronic patient 
record  team. 

4 

Mouth care matters 
. Staff complete 

mouthcare sections 
correctly on  Cerner 

Mouth care 
recommendation for 
patients who have 
been  identified  as  a 
swallowing  risk due to 
dysphagia 

Corrective  Mouth care 

Review and 
recommend  changes
to  electronic recording 
of mouth care matters
on  Cerner.  This wil l 
include Initial 
assessment to 
establish  base line. 

Directive  Mouth care 

Nurse rounding 
section  (Asist with 
food/fluid/mouthcare) 

Record  if assistance 
offered and accepted, 
declined etc

. 

June 2024 

Improved  record ing  of 
mouth care matters on 
Cerner 

Correct Cerner 
documentation in  place and 
staff aware of where to  record 
mouth  care

Improved recording  of 

Dec 2024 
(dependent  mouthcare assessment 
on  Cerner 
being 
updated) 

and  provides evidence that  Cerner of  patients with
mouthcare needs have 
been  met. 

dysphagia (from  Cerner list of
patients with  Dysphagia)

Complete audit of use of 
Mouth care recording  on 

5. 

SALT to  continue with  Preventative  Promote increased 
Swallow awareness 
training  rolling 
programme across 
wards 

awareness of 
swallowing difficulties 
and  SALT strategies 
with  supporting 
patients identified with 
swallowing  difficulties 

 and 

April 2024 

SALT team 

Audit how many wards 
have undertaken training 

Improved staff knowledge 
and  awareness of
dysphagia

Feedback to  Matrons wards 
that have participated  in 
training  and  identify  areas
that need  refresh  training . 

Gain  feedback from  staff by 
through  use of staff survey to 
measure success of training . 

4 

 
 
 
 
 
 Diary rolling  programme of 
training  across clinical 
areas 

6. 

Swallow awareness 
event 

Preventative 

"Remember 
Dysphagia" 

Nutrition  awareness 
11- 17  March  and 
swallow awareness 
day nutrition  week 
March  2024 

7. 

Review Meal time 
policy 

Preventative 

8. 

(Oral  Nutrition  and 
Hydration policy) 

Red  Tray guidance 
relaunch  (policy being 
updated) discussed 
at nutrition steering 
group. 

Preventative 

Promote swallow 
awareness as  part of 
swallow awareness 
day "Remember 
Dysphagia" 

 and 

SALT team 

March 
2024 

Events ·and  commutation 
(infographics etc) will  be 
available as  part of 
swallowing awareness day 

Improved staff and  general 
population  knowledge and 
awareness of dysphagia 

Materials produced  , 
information stand .  Internal 
and  external communications 
promoting  Dysphagia 
awareness. 

Carry  out staff survey to 
measure success of event. 

March 
2024 

March 
2024 

Updated policy ·improving 
the  importance of 
protective meal times, 
Patients receive a better 
meal time experience 
Raised  staff awareness 
about use of red  trays. 
Spot audit of use to  ensure 
red  trays are being  used 
appropriately 

' 

Updated  policy, 
Evidence from  PLACE Audit 

Evidence from  audit and 
feedback to ward  staff and 
matrons. 

Review evidence from 
PLACE Aud it 

Review Meal time 
policy to ensure it 
reflects current 
practice 

As part of Meal time 
policy review use of 
red  trays for all 
patients with 
additional 
needs and  requiring 
extra attention when 
eating , or heed foods 
that have a modified 
texture. 

(Clinical  lead for 
dietetics) 

(Clinical  lead for 
dietetics) 

Matrons ward 
staff 

5

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