Nikolas Clarke represented the local authority at the inquest into the death of a 49-year-old man, TM. TM had cerebral palsy and learning disabilities. He had undergone surgery as an infant to replace part of his oesophagus. The local authority had commissioned 24-hour care for him and also conducted a safeguarding enquiry after his death.
Background to the inquest
On 8 June 2021, TM’s carer gave him lunch as usual. Subsequently he seemed to be in a little discomfort so she patted him on the back to dislodge any obstruction and he appeared to settle.
Then they went to the park. About 90 minutes later the carer realised TM was unwell as he was coughing and repeatedly had phlegm on his face even after she had wiped it away. He was clearly in some difficulty and started to sweat. She took him home and called an ambulance.
Paramedics arrived within a few minutes and took over his care. TM was transferred to hospital but died later that day from a lack of oxygen to his brain caused by:
- food stuck in his oesophagus
- the long-term effects of his cerebral palsy
- complex surgery (when aged 18 months) resulting in a gradual deterioration of his oesophagus (that had previously remained undetected).
The pathologist, Dr O’Higgins found that TM’s oesophagus was very dilated and full of food. She concluded that resuscitation attempts would have been insufficient to clear TM’s airway and that it was an “accident waiting to happen”.
TM’s care plan was shown to be readily available to his carers and his carers had had mandatory training including on nutrition.
The coroner gave a narrative conclusion:
TM had undergone complex gastro-intestinal surgery when an infant to replace his oesophagus. He had a comprehensive speech and language assessment in 2012 and this contained clear instructions of how to manage his nutritional intake, and the emergency steps to take if choking occurred. Over time, but without becoming symptomatic, the oesophageal transplant became extremely distended so that food no longer passed through normally to the stomach. On 8 June, he aspirated but this did not present as an acute choking episode. Due to the complexities of his anatomy, resuscitation was unsuccessful. The evidence clearly demonstrated that this was not due to any errors, acts or omissions in his care.