There was a sense of “panic” in a disability care home in the aftermath of a resident dying after choking on some food, an independent review found.
Margaret Evans, who had an intellectual disability, died on October 25th, 2021, after choking on a piece of toast in a residential care home run by Sunbeam House Services.
An independent review into the death of the woman said it was “highly unlikely” the Heimlich manoeuvre could have been attempted, “given the speed of the impact of the health episode”.
The report, carried out by former Tusla chief executive Gordon Jeyes, found there was a lack of “crisis management guidelines” for staff, which it recommended be put in place.
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Managers who were informed of the incident by staff reported picking up a sense of “uncertainty and panic”, the report said.
Sunbeam House runs a number of residential centres for adults with intellectual disabilities in Co Wicklow, as well as respite and day services.
The review recommended an “urgent” reform of the role of person-in-charge, the staff member at the centre responsible for co-ordinating with management.
“On the day in question the designated person in charge admitted that they had not checked the rota sheet and did not know that the role had been allocated to them for the day,” the review said.
The duties of the position were “ambiguous and potentially confusing”, with no written statement outlining their responsibilities, it said.
Mr Jeyes said while the need for Sunbeam House to reform the role was “urgent”, it did not affect the outcome on the day Ms Evans died.
The independent review was released to The Irish Times following a Freedom of Information Act request.
Clear guidance
While the disability provider has a policy for how to provide end of life care to residents, this did not cover “circumstances of a sudden death”, Mr Jeyes said.
“It is crucial that there is clear guidance and a checklist to be used to review whether all necessary action has been taken,” he said.
Staff needed to be trained for how to respond to incidents like an emergency or sudden death, the report said.
Managers responded to the incident “in a sensitive and considerate way”, and ensured Ms Evans was “overseen with dignity until the undertaker arrived,” it said.
“This assistance was no doubt important but there remains the feeling that the response would have benefited from more immediate strategic co-ordination,” it added.
An inquest in Bray Courthouse in November heard Ms Evans had come into the staff office looking “off-colour” and was having difficulty breathing, before she collapsed.
Two care workers put Ms Evans in the recovery position and called the emergency services. The staff then started CPR compressions on her until paramedics arrived. The paramedics were unable to resuscitate her, and she was later pronounced dead.
A postmortem examination of the body found the “presence of small pieces of chewed bread present in the windpipe” and the inquest ruled she died by choking.
The review by Mr Jeyes said while a decision to send staff who had been on duty home was compassionate, “the opportunity to obtain immediate witness statements should have been taken”.
Witness statements were later sought via email which the report said was “not the most efficient and sensitive way of obtaining the most accurate and insightful narrative”.
Joe Lynch, chief executive of Sunbeam House, stated all recommendations made by the report would be “fully implemented”.
