A coroner has called for a review of systems at a Co Meath following the death by choking of a 90- year-old woman after she ate a piece of meat at a time when she was supposed to be on a “minced moist” diet. An inquest into the death of Margaret O’Reilly, formerly of Ford de Fyne, Co Meath and Howth Road, Dublin at Kilbrew Nursing Home, Ashbourne on 13th July 2023 was conducted by the Coroner for Meath Nathaniel Lacy at Trim Courthouse.
Garda Saoirse Horan told the inquest that she arrived at the nursing home at 3pm where she spoke to ambulance crew member Michael Rogers who said that Ms O’Reilly had been deceased by the time he arrived. The Garda said that she spoke with the nurse on duty Nisha George who provided a statement stating that Ms O’Reilly had started choking on her dinner and was brought to her room where attempts were made to dislodge the food but that she had gone into cardiac arrest and was not resuscitated. A statement was also obtained from care staff worker Noleen Salmon.
Managing Director Nurse Hima Bindu told the inquest that that Ms O’Reilly’s family agreed a “do not resuscitate” order in the event of a cardiac arrest. Olive Joyce, a niece of deceased had identified her remains. Consultant pathologist Professor Muna Sabah who carried out a post mortem told the inquest the deceased had a piece of material which was 3 centimeter’s x 2cm obstructing her larynx. There was
also fine material deep down in her airways. This was a piece of “white meat”. It was not “minced up” she said in a reply to the coroner. A toxicology report showed that her blood was negative for alcohol but had a drug Sertraline [an antidepressant medication] which was present “in toxic levels”.
The deceased’s body showed 2.6 micrograms whereas therapeutic levels should be 0.29mcg, nine times higher in her body than there was supposed to be. There were several explanations for that – she may have been given an extra dose but the pathologist could not say that for definite. A second explanation was that the drug did not clear her system. A third explanation could be that the drug clears the tissue and redistributes through the blood. But the primary finding was that of choking.
The piece of “white meat” obstructing the larynx could be chicken, she said. It was not minced. A redistribution of the drug post mortem could give a higher reading. The professor concluded that death was due to choking with an obstruction of the upper airways and pulmonary aspiration. The toxic level of the drug may have been a contributory factor in her death. However, she could not say that for certain.
Hima Bindu said she was in her office on the first floor when the emergency bell went. She went to the resident’s bedroom where she was moved after she became unresponsive in the dining room. NURSE Nisha George and care assistant Noeleen Salmon were supporting with a Heimlich man oeuvre. She recommended oxygen administration and helped move the resident to the recovery position on her bed. A few particles of food came from her mouth but the resident was still unresponsive. The resident’s vitals were checked but there was still no improvement. Nurse Nisha called the paramedic. There was no breathing and a “do not resuscitate” agreement was in place with the family.
Ms Bindu said she could not remember what the resident had for lunch but she was on a “minced moist diet” (minced meat and moist food and regular fluid). She added that Ms O’Reilly’s general health “was gradually going down in the months leading to her passing”. A doctor visited her occasionally in the nursing home and in June 2023 she was moved to hospital. In reply to questions from the coroner, Ms Bindu said that when the emergency bell rang she went downstairs. The choking started in the dining room and Ms O’Reilly was transferred to her bedroom. She had been in a wheelchair in the dining room. Nisha was performing the Heimlich man oeuvre
when she arrived in the room, she said.
She had taken over the man oeuvre from Nisha. Asked who was in the room when a decision was made to discontinue Heimlich, she replied herself, Noeleen and Nisha. The person who raised the alarm in the dining room was “Kate” who had since left the nursing home to continue her studies.
In further replies she said portions of food were checked by the staff before giving it to the residents. She could not explain how Ms O’Reilly had got a piece of meat in the size described by the pathologist. She also said that the resident had been removed from the dining room so as to avoid distress to other residents. It was a short distance from the dining room to the bedroom and Ms O’Reilly was already in a wheelchair. A review of the incident was carried out by the Health Information and Quality Authority (HIQA). Asked by a relative of Ms O’Reilly why other residents were not moved out of the dining room to allow for Ms O’Reilly to be treated there, Ms Bindu replied that some patients had mobility issues and some had dementia. She said that it was felt that for the safety of other residents it was quicker to remove Ms O’Reilly to her bedroom. The dining room was small and it might have been difficult to create a space to provide procedures
around the incident.
Following the incident she had had a special meeting with the nurses, health care assistants and kitchen staff to make sure the right portion and size of food was served to the residents. Nurse Nisha George told the inquest that Noeleen Salmon had come to her asking her to come quickly. When she went to the dining room she found Margaret with breathing difficulty sitting in her wheelchair. She identified food in her mouth and removed it with her fingers. She was still struggling to breathe and she was taken to her room via wheelchair. Ms Bindu performed the Heimlich man oeuvre. “She was still struggling to breathe so we transferred her into bed and tried a suction machine to attempt to take the particles of food and we administered her oxygen”. They continued to check her vital signs but saturation was dropping, She stopped breathing and did not have a pulse. The ambulance was called at 1.40pm and arrived at 2.15 when the paramedics
pronounced death.
Health care assistant Noeleen Salmon said that she was leaving one of the rooms after looking after a resident when Kate, also a health are assistant, called her to say that one of the residents, Ms O’Reilly, looked like she was choking in the dining room. She went to the dining room swiftly and went to Margaret’s side. She called her name “but she was unresponsive but lightly breathing”. When she was taken to her room she (Ms Salmon) and Nisha had propped her up in a chair and tried to dislodge whatever she had swallowed by slapping her on the back with her palm as shown in first aid training.
Asked by a family member if it was possible Margaret was given food from another resident’s plate, Ms Salmon replied “Oh no”. She said she had worked in the nursing home for 10 years and had not come across anything like that.
The coroner said that he found that Ms O’Reilly’s death was due to “choking with secondary pulmonary aspiration obstruction of the larynx and the bronchial tree. A contributory factor: toxic levels of Sertraline”. He returned a verdict of misadventure. In a recommendation following the return of the verdict, he said the file on the inquest should be sent to HIQA in terms of any investigation it was conducting. He also recommended that the nursing home, also in addition to whatever interaction it was having with HIQA, should carry out a review of its procedures in relation to reaction to choking hazards and he wanted confirmation of that from the nursing home.
Mr Lacy, along with the Deputy Coroner Donna Kerrigan, and Inspector Alan Roughneen extended their condolences to the family of the deceased.
