Wood Grange Care Home in Bourne has ‘learned lessons’ from man choking to death, inquest hears
Care home managers have ‘learned lessons’ after a man they were looking after choked to death while eating his dinner.
Chris Goulding, 81, was on a week’s respite at Wood Grange Care Home in West Road, Bourne, in May last year when he died.
The father-of-two lived in Bourne and was usually cared for by his wife, Helen.
Having suffered a stroke in 2009 and with the onset of conditions that included dementia, he had a care plan in place and an assessment that said he had ‘level 6’ dietary requirements. This meant certain foods were ‘high risk’ and much of his food needed cutting up into very small pieces.
On the day of his death, Mr Goulding had been offered a dinner menu with two options. He chose chicken nuggets, chips and baked beans. The other was a salad that included rocket and cucumber, which would also be classed as ‘high risk’.
Mr Goulding came down to the dining room to eat his meal, and it was here that he choked.
Staff attempted to unblock his airway with back slaps and abdominal thrusts. On phoning an ambulance they were told to administer CPR, which they did until paramedics arrived.
They were not able to save Mr Goulding’s life.
After the incident, staff were asked for statements about what happened and an inquest took place at Lincoln Coroner’s Court on Thursday last week (July 20).
The court heard a ‘pen portrait’ from his wife, who said her husband had grown up in Lincolnshire and spent some of his childhood in Egypt, where his father was serving in the RAF.
He learned to speak French and Spanish and became a teacher, working in Lincolnshire, in France and Tenerife.
He married at the age of 50 and was a ‘family man’ to his wife and two children, and remained as active as possible, even after his stroke. His wife described him as “the love of my life”.
Mr Goulding had stayed at Wood Grange on six occasions before May 2022, and the care home management had copies of his care plan and was made aware of his dietary needs.
His health issues meant he should have been ‘observed’ while eating - there was a member of staff nearby, but they were not specifically with him - and should not have been given certain foods, which included chips, breaded products such as chicken nuggets, and produce with skins, such as beans.
A medical report after Mr Goulding’s death found that he had food in his airway and had died as a result of choking.
Concerns raised in the aftermath of the incident, which the inquest heard has caused family members and staff great distress, included weaknesses in the sharing of information between staff, and in making sure all staff are aware of clients’ needs.
Care home managers had also not made Mr Goulding’s family aware that CPR would be performed by staff, if needed, in a choking incident, despite Mr Goulding having a wish not to be resuscitated.
In her narrative verdict, coroner Rachel Young said Mr Goulding “died from choking while eating and not being observed” despite observation being a requirement of his health assessment. Turning to the staff who had given evidence at the hearing, she said: “I appreciate you are all doing your best in very difficult circumstances.”
At the end of the inquest, Mrs Goulding asked if she could say a few words and, addressing three of the carers who gave evidence, said: “I do not want you to feel bad about this. I do not blame you for anything. If you see me in Bourne please do not run away.”
She added that Chris was a very forgiving man.
Barchester Healthcare has since made changes to its policies and practices. Wood Grange was inspected by the Care Quality Commission in July 2022 and received a ‘good’ rating, including for the category relating to client safety.
A spokesperson for Barchester Healthcare said: “We offer our condolences to the family of Mr Goulding. The coroner concluded that Mr Goulding came by his death following a choking incident and we acknowledge that conclusion.”