Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0420, written 12 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2025 |
|---|---|
| Reference | 2025-0420 |
| Deceased | Margaret Taylor |
| Coroner | Rebecca Ollivere |
| Coroner area | Gloucestershire |
| 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.
H M Assistant Coroner for Gloucestershire Ms Rebecca Ollivere REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Directors of Oak Tree Mews Care Home The Manager at Oak Tree Mews Care Home 1 CORONER I am Rebecca Ollivere, Assistant Coroner for the coroner area of Gloucestershire 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 25th November 2024, an investigation was commenced into the death of Margaret Taylor. The investigation concluded at the end of the inquest on 12th August 2025. The conclusion of the inquest was as set out below. 4 CIRCUMSTANCES OF THE DEATH Margaret (Maggie) Taylor was 80 years old and resided at Oak Tree Mews Care Home in Gloucestershire. She suffered with Dementia, and Dysphagia, and a Speech and Language Therapy (SALT) review, had identified her as a severe risk of choking. She was last assessed on 9th September 2024, and placed on a level 5 soft food diet and thickened fluids. Food was to be soft and mashed. No review of her SALT assessment was carried out in October 2024, however, she was taken off the level 5 diet and this communicated via a Whatsapp message to all staff at the care home. There does not appear to be any rationale for this decision, and it does not seem to be a decision taken following a proper assessment. On 8th November 2024, Maggie’s husband took into the care home, a chicken wrap, which he fed to Maggie. The evidence I heard was that he believed that Maggie had been removed from the soft food diet. He also indicated that the food was not checked for suitability by the staff at the home. I heard that this is against the policy of the home, which indicates that all food should be checked by staff. Sadly, Maggie began choking on a piece of chicken, and despite the best efforts of all involved, and paramedics who attended, she could not be resuscitated, and died at 12.40pm on 8th November 2024. The conclusion of the Inquest was that Margaret died as the result of an Accident. It is not known whether had the staff checked the food brought in by Mr Taylor, it would have been highlighted as not suitable, as she had been taken off the soft food diet, and so it may well be that it would still have been allowed. Therefore, I cannot say that there would have been any difference to the outcome for Maggie in this case had the staff checked the food. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk 5 CORONER’S CONCERNS During the course of the inquest the evidence 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. – - There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet - Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 7th October 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - Family 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 Date 12th August 2025 Assistant Coroner Rebecca Ollivere Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk
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 Coroners Administration Support O(cid:431)icer Gloucestershire Coroners Court Corinium Avenue Barnwood, Gloucestershire Dear , We are responding to the report received regarding the incident at Oak Tree Mews. We have taken this incident very seriously and have implemented several changes in the home. The manager at the time of the incident is no longer working at Oak Tree Mews due to personal reasons. The new manager incident and has worked alongside myself to implement the changes. has worked in care since 2003. She is fully aware of the carries out a full pre assessment which ensures all nutritional needs can be met, including allergies, swallowing di(cid:431)iculties etc. Care plans are created to ensure any SALT information etc. is included and they are updated as and when needed. When completing care plans all risks are identified and appropriate agencies would be involved and their advice followed. Care plans are updated regularly according to the needs of the residents, this will then be discussed with all sta(cid:431). A senior lead has been appointed to work alongside and sta(cid:431) to help with management and communication, as well as assisting the manager with paperwork etc. We have introduced protected lunch times where we encourage family members not to visit relatives at this time. The manager and myself when at the home are also present in the dining room during lunch service and regular meal time experiences are completed. The layout of our dining area has been changed as a result of completing a meal time experience to ensure that all residents are clearly visible whilst eating and that there is enough access room for residents and the sta(cid:431). Sta(cid:431) lunch breaks have been amended to ensure that all sta(cid:431) are present during lunch service. Family members were given a letter to explain about our protected lunch times and that we would like them to declare any food being brought onto the premises. We have a digital signing in system now for all visitors to the Home and on the screen we have a notice which they have acknowledge, reminding them to make sta(cid:431) aware of any food they are bringing onto the premises. We also encourage all our residents to have meals in the dining room to make them visible. All sta(cid:431) complete First Aid training on our online system. Sta(cid:431) have also had intensive in house first aid training, which was a course that lasts 3 years. Dependency levels are checked and updated to continue to ensure correct sta(cid:431)ing levels. We ensure that the quality of care provided is in the best interest of our residents.
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.