A care home failed to provide and deliver one-to-one, 24-hour care, according to an inquest, for a patient who choked to death on a rubber glove.
Chesterfield coroner’s court heard on Thursday, November 28, how 62-year-old patient David Rushby, of Oaklands Care Centre, on North Road, Langwith, collapsed outside his room despite an agreement that one-to-one, 24-hour care would be provided for him. He was later pronounced dead at Chesterfield Royal Hospital.
Dr Robert Hunter told the jury after the one-and-a-half week inquest: “There was a risk of choking with Mr Rushby being known to put objects into his mouth.
“Cardiopulminary resuscitation was administered and a paramedic removed a rubber glove from his mouth.
“He didn’t respond to CPR and was taken to Chesterfield Royal Hospital and further attempts to resuscitate were unsuccessful and he was pronounced dead.”
Retired clerical assistant Mr Rushby, who had mental health problems, was originally released from the Hartington Unit, at Chesterfield Royal Hospital, on May 5, 2009, according to the court, and moved to Oaklands under an agreement that one-to-one, 24-hour care would be provided.
The court heard how it was established Mr Rushby was at risk of swallowing inanimate objects and only days after his admission to Oaklands he was witnessed by a carer experiencing breathing difficulties before he collapsed and was pronounced dead on May 9. 2009.
Care assistant Sian Smith, who was on night-duty at Oaklands the evening before Mr Rushby died, told the inquest that staff had been advised not to sit in Mr Rushby’s room as he would sometimes become aggressive.
But Dr Hunter explained to the jury that NHS Derbyshire County primary care trust, who oversaw Mr Rushby’s care at the time, had provided funding to the home for a 24-hour, one-to-one care plan for Mr Rushby.
The jury which found Mr Rushby had died from an obstruction of his airway concluded he died as a result of an accident contributed to by neglect in circumstances where there was a failure to provide and deliver one-to-one, 24-hour care to effectively manage risks.
Following the death, Oaklands was taken over by HC-One care providers in 2011.