Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0408, written 18 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2025 |
|---|---|
| Reference | 2025-0408 |
| Deceased | Kathleen Gregory |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Beccles Medical Centre, Beccles, Suffolk 1 CORONER I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12 December 2023 I commenced an investigation into the death of Kathleen Mary GREGORY aged 74. The investigation concluded at the end of the inquest on 20 November 2024. The conclusion of the inquest was that: Accident The medical cause of death was confirmed as: 1a Asphyxia 1b Food in Airway 4 CIRCUMSTANCES OF THE DEATH On the 29th November 2023 at around 13:30 hours, Kathleen Mary GREGORY was found collapsed in bed by staff at her care home. She appeared to be choking on food which had earlier been left for her by staff for lunch. Staff sat Mrs. Gregory upright and checked to see if there were any obstructions in her upper airway. None could be observed. A paramedic who had been attending the care home was called to assist. Upon his arrival Mrs. Gregory had no pulse and did not appear to be breathing and he verified her death at 13:45 hours. A subsequent Post-mortem examination confirmed that Mrs. Gregory had died due to asphyxia caused by food which had become lodged at the larynx in her airway. Police enquiries revealed no suspicious circumstances or third party involvement in the death. 5 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) During the course of the Inquest the Court heard evidence that the paramedic employed by Beccles Medical Centre who attended Mrs. GREGORY on the 29th Regulation 28 – After Inquest Kathleen Mary GREGORY 02081-2023 November 2023 interpreted a Recommended Summary Care Plan for Emergency Care and Treatment (ReSPECT) in place at the time as meaning that resuscitation attempts should not be attempted in circumstances where an un-natural event such as choking was taking place. I am concerned that such an approach does not appear to be consistent with the terms of a ReSPECT Form and its application in circumstances of an event such as choking where an adverse outcome may be reversable. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 14th, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Kathleen Mary GREGORY Beccles Care Home I have also sent it to: The Care Quality Commission who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 18/06/2025 Darren STEWART OBE HM Area Coroner for Suffolk Regulation 28 – After Inquest Kathleen Mary GREGORY 02081-2023
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.
HM Coroner’s Court Beacon House White House Road Ipswich IP1 5PB Dear Mr. Stewart, 7th August 2025 Re. Kathleen Gregory: Prevention of Future Deaths Report (Ref. 2025-0408) I am writing in response to your recent Prevention of Future Deaths Report, regarding the above-named patient. I would like to start by extending my condolences again to the patient’s family. This case, I would agree, shows a reversible cause at the stage at which the patient was choking and had a pulse (was conscious). As per United Kingdom (UK) resuscitation guidance, one would attempt five back-blows followed by five abdominal thrusts (if the initial intervention was ineffective), in order to try and dislodge the obstruction. At the point at which the patient became pulseless/unresponsive (which as noted in the report was the case when the paramedic was notified of the incident) the patient by definition had gone into cardiac arrest and as per UK resuscitation guidelines one would then commence CPR at this point (ALS/backslaps). In terms of our RESPECT form conversations with patients, these would involve a discussion around what you (the patient) would like us to do in the event that your heart were to stop beating and you were to go into cardiac arrest. In the case of this particular patient, I feel that the window of reversibility had been lost at the point that they became unresponsive/pulseless since as per UK resuscitation guidelines the opportunity for interventions to dislodge the obstruction had passed. Consequently, CPR was then indicated, something which the patient had expressed on their RESPECT form that they didn't want to occur. Unfortunately, as may sometimes be the case, there isn't always a black and white answer, and in my opinion, this is such a situation. Although the RESPECT form is not a legally binding document, it is nonetheless a declaration of the patient’s wishes, wishes which are important and pertinent. I would also wish to observe that a patient with multiple comorbidities, who goes into cardiac arrest, may have a very small chance of recovery even where CPR has been administered. In summary, my opinion in regards to this particular scenario, would be that at the point at which the patient was choking and pulsed, they were reversible. However, from the point at which the patient became pulseless and was in cardiac arrest, any reversibility had gone and the RESPECT form would therefore become relevant. I agree that there is a degree of interpretation with regards to a RESPECT form in such a situation, and that therefore perhaps the wording or structure of the form needs to change. Naturally, this would be an issue for the national issuing body, but if it was felt to be relevant perhaps it is something that could be pursued with them directly. St Marys Road | Beccles | Suffolk | NR34 9NX - We are Research Active I recognise fully, and respect the premise, that where there are opportunities for any organisation to make changes, and implement learning that will improve patient care, these should be adopted and implemented in full. Accordingly, I would propose the following: 1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi- Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025. 2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks. 3. Further training for our clinical staff on the management of choking situations, has been arranged for Thursday 16th October 2025. 4. In the event that this case should have given rise to any sense that fundamental changes need to be made to the framework of RESPECT forms themselves (or the national guidance that supports their use and interpretation), I would urge you to take this up with the relevant national body. May I take this opportunity to thank you for furnishing us with your considered findings from this case. As a provider of medical services, we wish to assure all those concerned that we take these findings extremely seriously, and have sought to reflect upon their implications for our practice and the delivery of care to any patients in future. Please do not hesitate to contact me if I can be of any further assistance in this matter. Yours sincerely, GP Partner, Beccles Medical Centre St Marys Road | Beccles | Suffolk | NR34 9NX - We are Research Active
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