A patient who choked to death at a hospital run by Somerset Partnership Foundation Trust had been neglected by staff, a coroner has ruled.
Parkinson’s sufferer Diana Mansfield, 78, was struggling to swallow during her stay at Frome Community Hospital in September 2011.
On 3 September she choked and died. East Somerset coroner Tony Williams found the primary cause of death was acute upper airway obstruction and dysphagia, a common side effect of Parkinson’s.
Following the inquest in July he identified failings made in the nursing care received by Ms Mansfield and recorded a verdict of accidental death aggravated by neglect.
The Care Quality Commission visited the 28 bed hospital earlier this year in response to concerns about care and welfare of patients and staffing levels arising from Ms Mansfield’s death.
Inspectors judged the hospital was meeting standards overall. However it raised minor concerns about staffing levels, noting the ward had a sickness absence rate of nearly 10 per cent and cover was not always available for absent staff for a whole shift.
The full staffing establishment on the 12-bed ward where Ms Mansfield stayed was three registered nurses and four healthcare assistants on the early shift and five staff - usually two nurses and three HCAs - on the late shift. Some nurses complained this was not always adequate to meet the needs of patients and said it was sometimes a struggle to complete all their tasks.
Somerset Partnership took on responsibility for Somerset’s 13 community hospitals last year under the Transforming Community Services programme which required primary care trusts to separate their provider arms.
In a statement the trust said there were no staffing issues at the time of Ms Mansfield’s death. It highlighted that the coroner had been clear neglect was not the same as negligence.
The trust had now completed the process of introducing the use of dysphagia diet food Texture descriptors to its community hospitals to ensure patients with the condition got an appropriate and safe diet.
A spokesman said: “The Somerset Partnership NHS Foundation Trust has considered the events surrounding Mrs Mansfield’s death in great detail and has developed and implemented a detailed action plan focussing on the management of patients with dysphagia across both community and mental health services.”
Information supplied to HSJ and CQC report