A great-granddad who was unable to swallow died after hospital gave him a corned beef pasty and chips.
Norman Neal, 92, was rushed to University Hospital of North Tees after choking on a rich tea biscuit at Park House Care Home in Stockton.
He choked a second time after being served up corned beef pasty, chips and ice cream by employees on ward 40, according to Teesside Gazette .
An inquest at Teesside Coroner’s Court heard how workers failed to read medical notes.
The notes said Mr Neal, who was being treated with antibiotics and fluids, was “nil by mouth”.
Mr Neal’s medical notes later went missing and he was left without fluids for around five hours
Clare Bailey, senior coroner for Teesside and Hartlepool, heard how staff failed to ask the on-call doctor for more fluids for him when he ran out and did not place their new documents with the existing ones when they were found.
Mr Neal, a retired coal merchant from Oxbridge, Stockton, had been diagnosed with Alzheimer’s dementia.
He lived at the care home and was on a pureed food diet following a stroke which left him unable to swallow properly.
Although he was unable to consume solid food, he was normally able to to eat biscuits without any issues as he would dunk them in his tea to make them soft.
The two day inquest attended by Mr Neal’s three daughters, heard how he began to choke on a biscuit at the care home on July 18, 2017.
Care workers gave him back slaps and abdominal thrusts then CPR and a 999 ambulance was called.
Paramedics took over after arriving at the home and transported him to the hospital in Stockton for emergency treatment.
Doctor So Pye, consultant physician at the University Hospital of North Tees, told the court that Mr Neal was a 14 out of 15 in a scale of consciousness when he arrived at A&E – just one point below 100% which meant he would have been conscious and able to move his limbs and eyes.
When asked by the coroner if he had made a good recovery from the choking episode, Dr So Pye confirmed he had.
Mr Neal, who has six grandchildren and five great-grandchildren, was transferred from the emergency admission unit to ward 40 – the elderly medicine ward – the following day.
The inquest heard how the hospital’s procedure is that patients should be transferred to the ward by a health care assistant or a nurse if they are receiving oxygen or fluids in case there is a problem with their machine.
However the hearing was told how Mr Neal was transported by two porters.
Health care assistant Amy Lofthouse, who was working on ward 40, told the court: “We hadn’t had the handover to say he was nil by mouth so we assumed he was OK.
“We have had people come in with face masks with oxygen before and they have been OK to eat so we made the assumption.”
In her statement, she said Mr Neal had only taken one bite of the pasty before he went red and he was trying to cough.
She said: “It was a good size chunk of pasty that came out, probably the same size as a 10p piece.
“He wasn’t meant to eat or drink anything but we hadn’t been told that.”
Lynne Alston, associate practitioner, was also working on ward 40 at the time.
In her evidence, she said they noticed Mr Neal’s medical notes had gone missing after the incident and they weren’t found before they finished her shift at 8pm.
Ms Alston said she couldn’t recall if new medical notes had been started and told the inquest that she didn’t write anything down that evening.
Ms Bailey asked Ms Alston: “Did you have any idea of that the care plan was for Norman while on shift?”
She replied: “No, I don’t know.”
When the coroner asked Ms Alston if she agreed that not having a care plan would make it difficult to make sure Mr Neal got the appropriate treatment, she replied: “Yep”.
Ms Alston said she saw the notes at the beginning of the shift and then they went missing.
Mr Neal’s daughter Barbara Youhana asked her: “If the notes were there at the beginning did they not say they were nil by mouth?”
Ms Alston replied: “I didn’t look unfortunately, I was busy looking after another patient.”
The hearing was told how Mrs Youhana and her husband Aprim noticed food crumbs when they visited Mr Neal in the hospital that evening.
Mrs Youhana, asked nurse Karen Brown, who was also working on the ward, if she assumed that he was eating food.
During her evidence, Ms Brown said: “On the shift we all just assumed it yes.”
Ms Brown told the inquest how they were unable to find his notes later as they had become “misplaced”.
She said on-call doctor had visited Mr Neal and he had been left between 6pm and 11pm without any fluids.
When Ms Bailey asked her if the on-call doctor’s visit was potentially a missed opportunity to secure more fluids, Ms Brown replied: “It might have been yes.”
The coroner asked Ms Brown: “Do you think on this particular occasion there were lapses in care and the care wasn't to the standards it should have been?"
She responded: “The care was given to what we could do on that shift, it was lack of not knowing.”
Coroner Bailey pointed out that Mr Neal had done from 6pm until 11pm without fluids and asked if that would not suggest a lapse in care.
Ms Brown replied: “Possibly”.
Mrs Youhana asked Ms Brown: “You said you were a staff member down, do you think that's why things were missed?”
Ms Brown said: “I wouldn’t like to say.”
All three members of staff said they did not take the handover call when Mr Neal was transferred to the ward.
During the inquest, Coroner Bailey asked Doctor Helen Hodson, Consultant Physician at the hospital, if Mr Neal was expected to survive the admission.
She told the court how she was “very doubtful” after he came in with a background of conditions but said sometimes people do improve with time.
Doctor Hodson said: “I'm not actually surprised unfortunately that he did pass away.”
Mr Youhana said no one seems to know anything about anything and asked her if that was a safe environment for patients.
Doctor Hodson said: “This has been a very rare and unusual episode and that's what has brought us here. I'm sad that it's brought it here but very unusual.”
When asked about Mr Neal not being given fluid for five hours, Doctor Hodson said: “It’s not ideal but no I don’t think it’s had a significant impact.”
Mr Neal, who also served as a rear gunner in the RAF for the last two years of World War II, passed away on July 23 – five days after he was admitted to the hospital.
The inquest was told how North Tees and Hartlepool Hospitals NHS Foundation Trust, which runs the hospital, has made a number of changes to the way they work since Mr Neal’s death.
The court was told how they had been given additional training and now use an electronic system, with a back up paper file, instead of paper notes so they can’t be lost.
Larger boards have also been brought in and staff have been told to write in a certain corner using a particular colour.
The hearing heard how staff across the trust have also been reminded about the importance of the transfer check list by the patient.
The hearing was told how the hospital had seen an improvement following audits and expectations, but they could not always remove human error at the time.
Darren Elliott, who owns the care home, pointed out that hospitals use coloured bands to show staff that patients have allergies and questioned whether a similar method could be brought in for patients who are nil by mouth.
Ms Bailey told solicitor Gina Wells, representing the trust, that it was something she could take back to them to be considered.
Norman’s daughter Susan Bell told the coroner: “It’s just something that should never have happened, it’s a safe place at a hospital. I work in a hospital and I wouldn’t like it to happen to anybody else.”
Coroner Bailey told her: “The last thing I want is for there to be a repetition of what happened to Norman.”
The coroner ruled that Mr Neal’s medical cause of death was aspiration pneumonia, acute pericarditis and urinary sepsis .
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She said that chronic subdural haematoma, congestive cardiac failure and ischaemic and hypotensive heart disease contributed to his death. Ms Bailey highlighted that the hospital had failed to read Mr Neal’s medical notes, misplaced them and provided him with food.
She said they had also failed to ask on on-call doctor for more fluids when they ran out and had not placed newly written documents with existing ones when they were found.
The coroner said it was not possible to say who received the handover call when Mr Neal was transferred to ward 40.
She said: “Whoever took the call failed to inform their peers that Norman was nil by mouth, nor was it marked on the board.”
Ms Bailey said there were clearly issues in care and communication and missed opportunities in respect of ward 40 on the 19th July 2017.
She said: “My conclusion is that Norman died from natural causes contributed to by choking episodes on the 18th and 19th of July 2017.”
Ms Bailey told the hospital trust that they should take further steps so it’s clear that a patient is nil by mouth. Following the inquest, Mr Neal’s heartbroken daughter’s Barbara Youhana, Susan Bell and Dianne Minto, released a statement.
They said: “Unfortunately on this ward he was fed some solid food causing a further choking episode.
“The family believe this led to the deterioration in his clinical condition.
“Furthermore the nursing notes relating to this choking incident went missing and have never been located. Unfortunately dad died four days later on July 23.
“The family were disappointed that despite evidence in his medical notes that the transfer checklist from one ward to another was clear, including the telephone handover, the staff on the ward did not follow this, leading to a mistake.
“Following on from the coroner's Inquest into the death of our dad Norman Neal, we understand from all of the evidence presented that the University Hospital of North Tees have now introduced some new policies to reduce mistakes, similar to what happened to our dad.
“It's been four years that we as a family have been waiting for answers from the Trust.
“To see our much loved dad suffering in his hospital bed , was very sad and heart-breaking and we would not want this to happen to another family.”
A spokesperson for the trust said: “North Tees and Hartlepool NHS Foundation Trust and its staff share condolences with Mr Neal's family.
“We have been in contact with the family to respond to concerns they have raised with us and reviewed Mr Neal's care, alongside his family's concerns, which has helped to identify learning and introduce relevant changes.
“We recognise the coroner's conclusion and will be making no further comment at this time.”
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