Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0067, written 7 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2026 |
|---|---|
| Reference | 2026-0067 |
| Deceased | Bonita Cleary |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Curo Care Delaheys Ltd. C/O Delaheys Nursing Care Home 215 Clifton Drive South, Lytham St Annes FY8 1ES Care Quality Commission 1 CORONER I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUES The death of Bonita Cleary on 11th October 2025 at Delaheys Nursing Care Home, Lytham St. Annes was reported to me and I opened an investigation which concluded by way of an inquest on 8th January 2026. I determined that the medical cause of death was: 1a Choking 1b 1c 1d II Severe frailty, left ventricular hypertrophy, coronary heart disease, dementia. In box 3 of the Record of Inquest I recorded as follows: Bonita Cleary was aged 75 years. Her medical history included dementia and she was known to be severely frail. She was not regarded as being at risk of choking, but sufficiently frail that when eating, her food needed to be easy to chew and a member of staff present. On 11th October 2025, at a time when a Care Assistant had commenced feeding her small portions of crumpet for lunch, Bonita started coughing and had what has been described as a vacant episode. Her jaw became clenched. She began choking and the food caused an obstruction of her airway. She had a DNACPR [Do Not Attempt Cardio – Pulmonary Resuscitation] authorisation in place. CPR was not initially commenced with a view to trying to reverse the effects of choking until a Paramedic attended who was able to remove food from Bonita’s airway but by that stage from the available evidence she could not be revived. A subsequent post – mortem examination confirmed she died from the effects of choking, her death more than minimally contributed to by her known severe frailty, compromised heart function, and dementia. In box 4 of the Record of Inquest I determined that: Misadventure 4 CIRCUMSTANCES OF THE DEATH In addition to the contents of section 3 above, the following is of note: Bonita Cleary was largely bedbound during her final weeks; She was not regarded as at significant risk of choking, and she was not restricted in terms of the range of foods she could eat, but there was a need to for a member of staff to be with her when she ate; With a member of staff in attendance, she began eating some pieces of crumpet which had been cut up for her; She did have a history of what were described as seizures / vacant episodes of varying duration, and on such occasions her jaw could become clenched and lock; This happened unexpectedly after she began eating the crumpet, and she appeared to be choking. A member of care staff, and then a nurse, both of whom were familiar with Bonita and had cared for her for many months, tried to assist her by making attempts to clear any food from her mouth; When a paramedic attended, CPR was not being performed; The Paramedic made efforts to remove more food from the airway, and commenced CPR, but in due course it was confirmed Bonita had died; There was a DNACPR (Do Not Attempt Cardio-pulmonary resuscitation) authorisation in place; It seems there was a lack of awareness that even if there is a DNACPR in place, CPR can be commenced to respond to potentially reversible causes. Choking is one such reversible cause; The Nurse gave helpful evidence at the inquest, whilst acknowledging that despite her years of experience, and had previously received basic life support training, she was not fully aware that CPR may still be required in the event of a potentially reversible cause and she firmly expressed the view there is a lack of guidance on this issues for medical professionals and care workers employed in a care setting. A senior manager in attendance at the inquest agreed. I considered if, had effective CPR been commenced immediately, this would have made a difference to the outcome for Bonita? Although I could not rule this out, I regarded it as unlikely. Having considered all of the above, I have determined that I have a duty to write this report. 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 send the report: The MATTER OF CONCERN is as follows. – Bonita Cleary died due to a choking episode. This is a potentially reversible cause. Notwithstanding there was a DNACPR authorization in place, CPR ought to have been commenced On balance of probabilities, this would not have saved Bonita’s life, but for other vulnerable residents in a care setting, effective and timely CPR may prevent death; I am concerned that there is a lack of awareness amongst care and nursing staff within this organization and the care sector more widely about when CPR should be attempted, and that residents with a realistic chance of surviving may die as a result of a cause which was, in fact, potentially reversible. It is not for me to be prescriptive about what can / should be done, but there is a clear risk and therefore I raise this concern. 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, and therefore by 5th April 2026. I, the Coroner, may extend the period further. 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: The family of Bonita Cleary 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. She may send a copy of this report to any person who she 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 07/02/26 Signature_________________________ Alan Anthony Wilson Senior Coroner Blackpool & Fylde
2 responses 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.
Dear Mr Wilson
Thank you for sending us the Regulation 28 report regarding Delaheys Nursing Care Home and
the sad death of Bonita Cleary.
I was unsure if CQC were a named responder or if the Regulation 28 report was for our
information/intelligence. Please could you let me know?
I hope the following is of use in the interim:
CQC inspectors have re-assessed our analysis of the original notification of death by the provider
and been in touch with the provider to gain assurances about people's immediate safety, about
what lessons can be learned from the incident, and the evident need for further exploration of the
DNACPR/reversible cause considerations.
In terms of re-inspecting the service we have considered this. We have assessed other recent
cases and notifications to see if there if there are other areas of concern, and will continue to
review this dependent on the assurances we receive from the service. It is pertinent to note that,
from January, CQC has reviewed its approach to prioritising inspections, meaning that this
service falls into one of the higher priority categories: "Services with older ratings, to keep ratings
current and reliable." We will therefore look at lessons learned from this incident at that next
inspection. I cannot confirm the date of that inspection at this time as it will depend our scheduling
of inspections quarter by quarter, but it will be comprehensive and unannounced, and is
categorised as a priority.
In the meantime, we have shared the broader concerns raised regarding understanding of
DNACPRs where there may be a reversible cause, with our Senior Specialists team. They have
responsibility in CQC for upskilling staff in areas of practice. CQC is responsible for ensuring
providers are compliant with regulations, but it also has an improvement function - thank you for
highlighting this area of concern regarding training/knowledge, which the senior specialists will
review.
* Please could you also confirm if you give consent for us to share the report with
* Please could you confirm if you require anything further from CQC regarding
•
this matter?
•
the care home's commissioners at the local authority, to inform their local quality and
safety oversight arrangements (who may consider the broader DNACPR issue across
all their services)?
Many thanks for your help with this matter. Please feel free to call me if you have any questions.
Kind Regards
Operations Manager
Care Quality Commission
Network North
Operations Group
*Please DO NOT reply to this email address as it is not monitored. Please direct all responses to
enquiries@cqc.org.uk quoting your unique case number.
Regulation 28 Action Plan – Delahey’s Nursing Home and Curo Care Collective Coroner: Alan Anthony Wilson Date of Report: 1st of March 2026 Regulation 28 Reference: Service A(cid:431)ected: Curo Care Delahey’s Ltd. Lead Responsible Person: Operations Director and Ainslie Fotheringham Registered manager Matter of Concern Bonita Cleary died during a choking episode, and this is potentially reversive cause Notwithstanding there was a DNR CPR authorisation in place, CPR ought to have been commenced On balance of probabilities, this would not have served Bonita’s life, but for other vulnerable residents in a care setting e(cid:431)ective and timely CPR may prevent death The coroner is concerned that there is a lack of awareness amongst care and nursing sta(cid:431) in Curo Care and the care sector more widely about when CPR should be attempted, and that residents with a realistic chance of surviving may die as a result of a cause which was in fact potentially reversible 1 Delahey’s Nursing Home Action Taken The learning from this incident has been shared across all homes within the organisation to ensure consistent understanding of DNACPR decisions and the requirement to commence CPR if a reversible cause, such as choking, is present. Action Date Evidence Responsible Notifications sent to CQC and Safeguarding Root Cause Analysis Investigation for Serious Incident Concluded Colleague Welfare: team reminded that they have free access to Wisdom, the digital wellbeing platform linked to Curo Care’s Employee Assistance Programme. This includes a 24/7 confidential counselling helpline and o(cid:431)ers additional support for colleagues a(cid:431)ected by distressing events. 12/10/2025. CQC statutory Notification resent to CQC 18/10/25 15/02/26 CQC receipt reference number NOT-013368649 Appendix 1. Incident Report At all handovers for a week following the incident Wisdom poster with contact details in sta(cid:431) room Sta(cid:431) recompleted E-learning modules in Choking, IDDSI, Dysphagia, Seizure Management and Basic Life Support. 15/10/2025 – 22/10/2025 Appendix 2. training matrix All colleagues read and signed policies: Seizure Policy and Basic Life Support Policy. 15/10/2025 -23/10/25 All Colleagues completed Assisting Residents to Eat and Drink Competency assessments. 14/10/2025 – 22/10/2025 Face-to-face First Aid training (6 hours per session) commissioned for all colleagues, covering choking management, airway management, BLS, seizure response and escalation protocols. *Included a section on reversible causes 24 - 25th Feb 2026 2 Signed sheets are available for policy reading confirmation if required Appendix 3. Competency Assessment – Assisting Residents to eat and drink. Awaiting First Aid Certificates Both the nurse and care assistant have reflected and completed a written reflective accounts Group supervision sessions were held with all colleagues to: Reinforce the importance of high-quality documentation and to thank sta(cid:431) for the detailed records within BC’s care plan Provide further clarification and discussion around DNACPR decisions and reversible causes A dedicated section on DNACPR and reversible causes has been added to all sta(cid:431) induction programmes at Delaheys Reflection from Carer received 19/10/2025, Nurse reflection account received 18/02/2026 6 sessions held to cover all sta(cid:431) between the dates of 15/01/26 - 21/01/2026 Appendix 5. Nurse reflection Appendix 6. CA reflection Appendix 7. Group Supervision Template for DNACPR Temporary fix – added to the home’s induction from February until new company induction paperwork is developed to include guidance on DNACPR and reversible causes. Appendix 8 Induction. New colleagues will receive also training and complete a competency assessment to ensure understanding. A LifeVac Wall-Mounted Airway Clearance Device Kit was purchased and introduced within the home. 05/11/25 Appendix 4. copy of LifeVac invoice 3 Curo Care Group Learning and Improvement Actions Following this incident, a full review and root cause analysis were undertaken to understand the circumstances and identify learning. Immediate actions were implemented within the home and across the wider organisation to strengthen sta(cid:431) understanding of DNACPR decisions, particularly in relation to reversible causes such as choking, and to reinforce both choking prevention and emergency response procedures. The actions below set out the steps taken across the organisation to address the coroner’s concerns and reduce the risk of a similar incident occurring in the future. Action Specific Steps Awareness and learning: ensure all Registered Managers are aware of DNACPR and reversible causes Follow up with managers face to face to ensure DNACPR and reversible causes is understood Cascade the information to sta(cid:431) across the group DNACPR Circular from Care Sector Clinical Lead - South Cumbria & Morecambe Bay NHS Lancashire and South Cumbria Integrated Care Board A workshop was held at the January Home Managers’ meeting to review the incident and revisit DNACPR understanding. The Delahey’s Manager shared her experience, and key learning points from the Inquest were discussed. Managers cascaded the learning to their teams using a variety of methods including supervisions, one to ones, sta(cid:431) meetings, huddles, flash meetings and handovers. Responsible Person/s Completion Date 09/01/26 Evidence of Completion High priority email sent to managers *Email available if required How Impact Will Be Monitored With follow up and discussion Face to Face at next managers’ meeting 26/01/26 Appendix 9 Managers’ Meeting Minutes (other non- relevant actions and discussions redacted) Discussed at meeting and again at subsequent operations director home visits throughout February Home Managers 26/01/26 – 17/02/26 Response email from all managers confirming completion sent to operations director 18/02/26 Spot checks in home visits by operations director and regional operations manager 4 Provide care home teams with a reference leaflet Confirm colleague understanding Managers shared an information leaflet for sta(cid:431) to refer to in the homes. Ops director shared the link that CQC sent with the HMs so that they can print the document and make available to sta(cid:431). A DNACPR competency has been developed and will be completed with all sta(cid:431), with signed copies retained on file, (please note: a draft version is attached) Home Managers Home Managers 17/02/26 Appendix 10. Leaflet. Email confirming completion sent to operations director Spot checks in home visits by operations director and regional operations manager 17/02/26 Appendix 11. DNACPR Competency Assessment Reinforce that 999 should be called immediately if choking is not relieved quickly. Reinforce through meetings and handovers that emergency services should be contacted promptly where choking is not immediately relieved. Home Managers First Aid Training Provider ViTa 31/03/26 Handovers and team meeting notes confirming that the guidance has been communicated to sta(cid:431). Introduce LifeVac equipment across all homes in the group Emergency equipment locations will be reviewed and communicated so that colleagues can access equipment immediately in an emergency. Training will be undertaken by all sta(cid:431) Home Managers 31/03/26 All homes will have a LifeVac in place Sta(cid:431) training and understanding will be recorded – Appendix 14. 5 This competency check is being prioritised, and all colleagues will have one in place by 31/03/26. Spot checks will be undertaken during senior management visits Sta(cid:431) knowledge checked through supervision, competency assessments and informal questioning during spot checks. Incident report reviews will confirm that 999 is called promptly where choking incidents occur. Sta(cid:431) will have access to an airway clearance device that may help where standard choking procedures have been unsuccessful. Ensure all new colleagues are aware of DNACPR and reversible causes when they join the company DNACPR and reversible causes to be part of new induction, currently under development Home Managers 30/04/26 Under development Company external training to include DNACPR and reversible causes Shared information with the company that delivers First Aid training (ViTa) so they can update the training for Curo and others in the sector Verbally 26/01/26 Formal email sent to New induction paperwork is being developed to include guidance on DNACPR and reversible causes. NB in the meantime, new colleagues will receive training and complete a competency assessment to ensure understanding. Colleagues will have a greater level of practical knowledge and understanding of CPR, including when it must be commenced. If QUAL SAFE takes this into account, the knowledge will be widespread Colleague knowledge about DNACPR and reversible causes will be widely understood, reinforced, and accessible to all colleagues. This will also be renewable training. *Email available if required 04/03/26 Response – agreed to incorporate and they will also contact QUAL SAFE, the awarding organisation that develops and accredits first aid, health & safety, and pre- hospital care qualifications (regulated by Ofqual) with the recommendation to incorporate formally. *Emails available if required Follow up email sent 04/03/26 to Company E-learning to needs to include DNACPR and reversible causes Your Hippo to be informed that reversible causes should be part of basic life eLearning training. This should impact other care providers using By phone on 03/03: YH agreed to incorporate this into Basic Life Support E-learning. 6 Create a specific DNACPR Policy New DNACPR policy written to be shared with all new and existing sta(cid:431) once implemented Written: 02/03/26 Appendix 12. Sent to QCS who provides policy templates, and guidance for regulated care providers such as care homes. Ensure DNACPR Policy is added to library and learning is shared with QCS Add to Curo policy library but inform QCS why we are adding the DNACPR policy so they can write their own which can be shared with other care providers using their policies. Email to on 04/03/26, delivered and read. * Emails are available Sent to QCS to add to Curo Homes’ library: 04/03/26 Response from QCS confirming they will write a policy and share it with all providers by 13/03/26. 7 A DNACPR specific policy will provide clear guidance to sta(cid:431) on what a DNACPR means and when CPR must still be commenced. It supports safe decision-making, protects residents’ wishes, and helps ensure sta(cid:431) respond appropriately in an emergency. The policy will be added to Curo homes’ library immediately. However it will be reviewed and added to the wider library Colleagues across the sector will have accessible clear guidance on what a DNACPR means and when CPR must still be commenced. It will support safe decision-making and help ensure sta(cid:431) using the policy in all settings respond appropriately in an emergency Care Plans must include a DNACPR reversible causes note Managers to review and update all care plans to include a DNACPR reversible causes note where applicable. Home Managers *Email available Emailed instructions to managers on 23/02/26 Target completion date is 31/03/26 Ensure both choking prevention measures and emergency response guidance are reflected in care plans Care plans for those residents diagnosed with seizures will be reviewed and a note added that states there is potential for seizure during eating, which would cause change in state of consciousness. Home Managers By 31/03/26 Note to be added to all other care plans to remind sta(cid:431) that if the person becomes unresponsive while eating, it should be treated as a possible choking emergency and to follow the choking response procedure immediately and emergency services should be called promptly (& if cardiac arrest occurs as a result of a reversible cause, such as choking, CPR must be started) 8 Email instruction issued to all managers confirming the required wording and timescale for completion. *Email available if required Spot checks and audits of a sample of care plans during senior management visits, report compliance on provider visit record All care plans will contain a reminder to clarify that the DNACPR applies only if the resident’s heart stops naturally and CPR must still be commenced if the cardiac arrest is caused by a potentially reversible event. This note will then be personalised following speaking with the resident/ family/ LPA. This will be checked during quality checks Check of care plan audits during quality checks. Spot checks during provider visits to ensure sta(cid:431) are aware of the guidance. Ongoing monitoring of incidents Review of sta(cid:431) understanding during DNACPR competency assessments Regular review of residents with known choking risk Discuss DNACPR limitations with resident and/ or family Choking risk assessments will continue to be reviewed regularly to ensure appropriate supervision, positioning and food texture guidance are in place. Discussions with residents and families will include clarification that DNACPR applies only to natural cardiac arrest and does not prevent intervention where the cause is reversible. Home Managers 31/03/26 Care reviews Care Plan Audits Home Managers 30/04/26 Care plan entries in reviews to show DNACPR discussions have taken place Residents with choking risks will have the right supervision, positioning and food textures in place, reducing the likelihood of choking incidents. Care plan audits will confirm DNACPR discussions. Spot checks during management visits Feedback from residents and families during reviews or meetings confirming understanding Incident reviews These actions will be monitored through the company’s governance framework. Compliance will be reviewed through care plan audits, training compliance monitoring, competency assessments, and spot checks made during senior management and provider visits. Any choking incidents or emergency responses will be reviewed through our incident reporting system to make certain that emergency services are contacted promptly and that CPR is commenced where a reversible cause is identified. Learning from incidents will continue to be shared across Curo Care to reinforce safe practice. 9
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