Advising with empathy and experience

Resident choked in care home.

Carers at a North Yorkshire nursing home short-staffed on the weekend that the Tour de France visited, stepped over the body of a choking resident as paramedics battled to revive him, an inquest heard.

The inquest at Harrogate Magistrates Court into the death of William O’Connell, 76, heard that some staff had been unable to travel to work at Alexander Court Care Home, Duchy Road, Harrogate, by public transport.

As a result, the 85-bed care home was two staff short on Sunday July 6 when Mr O’Connell died, with just three carers and two nurses covering a workload usually met by seven or eight staff.

The inquest was told that people in the care home dining room had stepped over Mr O’Connell’s body as paramedics tried desperately to resuscitate him.

Paramedic Paul Fairclough said: “When we arrived there was a gentleman on the floor unconscious. The patients were still being fed and staff were stepping over trying to collect meals.”

Coroner Mr Turnbull replied: “It must have been difficult to deal with people actually stepping over. Do you recall any of the patients being moved away?”

Mr Fairclough said: “Only when my colleague spoke to them.”

Another paramedic, Gordon Pollard, said that Mr O’Connell had been sitting on a  recliner chair in the dining room for about five minutes when he stopped breathing. They measured no pulse and he was confirmed dead shortly after their arrival.

Carl Gray, who carried out the post mortem, said Mr O’Connell “had foodstuffs in his airways comprised of whole chips, bits of chicken and some vegetables”, in spite of records stating he required a soft diet of food mashed up due to him not having teeth or dentures.

“There were large-scale chunks of food which had gone through the larynx into the trachea”, he added. This was the worst case of trapped airways I’ve ever seen.”

Mr Turnbull said: “I’ve been told Mr O’Connell needed his food to be mashed up”, to which Dr Gray replied: “That does not comply with what I saw. There was whole food, certainly not mashed and quite big.”

Nurse Mirela Tibuleac earlier told the court it was her first shift as a qualified nurse when Mr O’Connell died. She said: “We couldn’t supervise the residents properly and do the rest of the tasks. We tried to call for other staff but none came because how would we transport them?”

During an inspection in March 2014 the CQC found a catalogue of errors at the care home, which charged between £550 and £725 per week. Residents were at risk of malnutrition and the home failed to ensure people’s safety and welfare.

Ruling a narrative verdict, coroner Rob Turnbull said: “The cause of death is obstruction of the airways by food, which was caused second-hand by his Parkinson’s disease. I record a narrative verdict. It’s clear nothing could have been done to prevent Mr O’Connell’s death.”


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