Alan Lee

Care Outlook Ltd 
Response to Coroners Report in respect of Mr Alan Lee 

Date of coroners report: 06/06/2024 
Ref: 2024-0308 
Deceased name: Alan Lee 
Coroner name: Penelope Schofield 
Coroner Area: West Sussex, Brighton and Hove 

Background 

Mr Alan Lee (AL) lived in his home, 

 at Abbotswood extra care scheme in Rustington, West Sussex. 

AL was supported by Care Outlook who were commissioned by West Sussex County Council to provide 4 visits per day to assist with 
personal care and daily living activities.  Care Outlook had been the care provider for AL since 11/09/2023. 

AL would usually go down to the dining room daily for his lunch and was escorted by care staff to go to the dining room and to return after 
eating; care staff did not remain with AL while in the dining room and he would eat independently.  On occasion AL would prefer to eat his 
lunch in his home and when that was his preference care staff would deliver his lunch to him and then leave him to eat independently. 

AL had no known history of choking and ate his meals independently. 

Coroners Report 

CORONER’S CONCERNS 
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths 
could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it 
had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking. 
Therefore, no life saving techniques were attempted. 

 
 
 
 
 
 
 
 
  
  
 
 ACTION SHOULD BE TAKEN 
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such 
action. 

YOUR RESPONSE 
You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2024. I, the coroner, may 
extend the period. 

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

Response 

Prior to this incident our staff received both theory and practical training on Dysphagia and modified diets and Basic Life Support (BLS); this 
training is a blended learning approach of e-learning and classroom based. 

BLS training included choking risks and responses with practical demonstrations of appropriate actions including “back strikes” and 
“abdominal thrusts”.  Dysphagia and modified diets training included causes and effects of swallowing difficulties, signs of choking and 
appropriate action to be taken in the event of choking. 

The staff we employ at our services are not medically trained personnel and there will always be limits to their ability to identify the causes of 
a medical emergency, however our training is designed to support the provision of immediate and basic life saving techniques where 
appropriate. 

We have reviewed our training provision and have made some changes in the design and delivery of this to strengthen the courses and to 
provide staff with greater confidence in the future. 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action 
Purchase of a choking vest 

Detail 
The training team purchased a Choking Vest to incorporate into the practical BLS training we deliver. 

BLS training has always included choking risks and responses with practical demonstrations of appropriate 
actions including “back strikes” and “abdominal thrusts”, the Choking Vest provides an additional tool for 
staff to be able to carry out a more hands on practice of these actions. 

For information – this is a link to the type of device purchased: https://shop.rlss.org.uk/products/choking-
rescue-trainer-vest 

Development of training plan 

The training team developed a lesson plan for the delivery of the additional practical element of the 
choking training which can be delivered as a standalone session and can be incorporated into the existing 
BLS training session currently delivered during induction and refresher training. 

Training includes the signs / symptoms & actions in the event of choking. 

The trainer delivers a section on how a person might present physically/visually if they are choking and 
how this may differ from other causes. 

The training covers choking for people in a variety of reposes including sitting, standing and laying down. 

The training includes a practical demonstration by the trainer of actions to take in the event of choking, 
using the Choking Vest as a training tool.  Trainees are then required to practice these actions using the 
Choking Vest under the guidance of the trainer. 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 Action 
Roll out of training with choking 
vest 

Detail 
The new practical session was rolled out to services as a standalone session beginning on 01/07/2024. 

Services in West Sussex were prioritised for the delivery of these sessions; delivery in West Sussex was 
completed on 24/07/2024. 

In addition, the training team are creating a recorded session with practical demonstrations using the 
choking vest which will be available to all staff across the business online and will be accessible at any 
time for refreshers via our e-learning platform.  The recording has been completed and is now in the 
editing stages with the intention to have this live on the system before the end of August 2024. 

Incorporation of choking vest 
training to induction and 
refresher 

As noted above the lesson plan created by the training team can be delivered standalone or as part of the 
existing mandatory BLS training delivered during induction and refresher training. 

The amended lesson plan for all BLS training has been active since 09/07/2024 and from this time all new 
staff attending Induction training will receive the updated training with the choking vest and all staff 
attending refresher training will also receive the updated training with the choking vest. 

Increased frequency of e-
learning 

All staff complete e-learning on Dysphagia and Modified Diets as part of their Induction.  This training has 
been set to an increased refresher frequency of annually. 

This training covers causes and effects of swallowing difficulties, signs of choking and appropriate action 
to be taken in the event of choking. 

 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
  
 Action 
Expansion on eating and 
drinking risk assessment 

Detail 
We have expanded our nutrition and hydration assessment to include a standalone risk assessment tool of 
an ‘Eating and Drinking Checklist’.  This assessment document provides additional, specific questions to 
highlight choking risk and record involvement from health care professionals such as the SALT Team. 

This information was previously recorded within the Needs Assessment under Nutrition and Hydration; we 
are now providing this as a separate document and enhancing with specific questions highlighting risk of 
choking and the control measures needed to manage this risk. 

The use of this new document will be rolled out to all services by the end of August 2024.