A 62-year-old woman with difficulty swallowing died from a cardiac arrest triggered by choking on food she wasn’t supposed to eat, an inquest heard last week.
Lesley Bocking, who had learning disabilities and limited mental capacity to understand the risks associated with eating the wrong foods, had been living in shared, supported living accommodation in South Wootton Lane in King’s Lynn.
Her care plan restricted her diet to soft, easily swallowed food in small, 1.5cm x 1.5cm “Malteser-sized” pieces.
But on February 1 last year, Lesley helped herself to some ham from the communal fridge, the inquest heard.
Lesley had been asking the bungalow’s support worker for a yoghurt, who in turn asked Lesley to wait until she returned from putting medication away.
When the support worker came back to the kitchen moments later she found Lesley eating the meat and told her to spit it out as in line with the care plan, and Lesley spat out a “golf ball-sized” piece of ham.
She then began to choke and the support worker’s efforts to help dislodge trapped food through administering back slaps failed to help, so she performed the Heimlich manoeuvre twice. When Lesley collapsed in her arms, she laid her on the floor and then managed to remove some more ham from Lesley’s mouth.
The support worker then dialled 999 and paramedics arrived around two minutes later and took over, performing CPR, the inquest was told.
Lesley was taken to the Queen Elizabeth Hospital in Lynn by ambulance but remained unresponsive at hospital.
She died at 2.34am the following morning, surrounded by her parents.
The inquest heard Lesley’s mum Audrey considered the death to be an accident which could not have been prevented, and did not seek to blame anyone, but a safeguarding investigation by Norfolk County Council found the care providers, Dimensions UK, had been neglectful by using an out-of-date assessment report on Lesley which allowed her greater choice over her diet.
The old assessment, dating from 2017, said Lesley had capacity to understand the risks associated with eating foods not covered by her restricted diet, and that “Lesley has the right to make an unwise decision” as long as staff were there to support her while she ate.
However, the inquest heard that an updated assessment from 2022 had found Lesley’s capacity to comprehend such issues was by then more limited and she was no longer meant to have access to food difficult to swallow and therefore potentially dangerous to her health.
Dimensions UK had also assessed the likelihood of a serious incident occurring to be low and therefore felt a risk assessment was not needed.
Although Lesley was told which foods she should and shouldn’t eat and was generally “very careful”, it was known she would sometimes take food she was not supposed to be eating, either from the kitchen or from the plates of her two housemates.
In written evidence from Lesley’s father read out at the inquest, he said his daughter appeared happy and well-looked after by the care providers.
He added: “She rang up every day for a short conversation and always sounded happy. She also looked forward to our visits and looked clean and well, and well-looked after.”
He said Lesley had called them the day before she died and “was the same, happy person”.
The county council safeguarding report also added: “Miss Bocking’s mum, Audrey, was consulted following Miss Bocking’s death.
“Audrey felt Miss Bocking received good quality care from Dimensions during her time there and she had no areas of concern.
“Audrey is understandably saddened by Miss Bocking’s death but sees the incident as an accident which couldn’t have been avoided.
“She does not want anyone to be implicated or blamed for her death.”
Lesley’s medical cause of death was given as respiratory arrest caused by airway obstruction, in turn caused by and choking on food, with a contributory factor being a range of pre-existing medical conditions, including her difficulty in swallowing.
Having heard extensive evidence, Norfolk Coroner Christopher Leach gave a conclusion of accidental death.
He said he did not need to write a Prevention of Future Deaths report, which is something coroners can do following a death, as he was satisfied with expert evidence suggesting there was little to no risk of other people in the region suffering a similar death.