Medic did not attempt to revive care home resident

Kathleen Gregory had been living at Beccles Care Home at the time of her death

A coroner feared there was a "risk of future deaths" after a paramedic made no attempts to resuscitate an elderly care home resident who choked on her lunch.

Kathleen Gregory died of asphyxia at Beccles Care Home, in St George's Road, Beccles, Suffolk, on 29 November 2023 after food became lodged in her throat.

After efforts were made to help her, a paramedic from Beccles Medical Centre found she had no pulse and was no longer breathing before confirming her death.

Area coroner Darren Stewart OBE said the paramedic incorrectly believed they did not need to attempt to resuscitate 74-year-old Mrs Gregory when this was not the case.

Mrs Gregory choked on her lunch and had no pulse

In a Prevention of Future Deaths Report, he said the paramedic had misinterpreted a Recommended Summary Care Plan for Emergency Care and Treatment (ReSPECT).

Mr Stewart said the medic thought "resuscitation attempts should not be attempted in circumstances where an unnatural event such as choking was taking place".

"I am concerned that such an approach does not appear to be consistent with the terms of a ReSPECT form and its application in circumstances of an event such as choking, where an adverse outcome may be reversible," he added.

The paramedic who responded to the emergency was employed by the Beccles Medical Centre

During an inquest, a court heard how Mrs Gregory had been found collapsed on her bed and appeared to be choking on lunch which was earlier provided by carers.

Staff at the home, in St George's Road, had sat Mrs Gregory upright and checked to see if there were any obstructions in her upper airway, but none were observed.

The paramedic then verified her death at 13:45 GMT.

'Action should be taken'

After an investigation into how Mrs Gregory died, Mr Stewart ruled that, while her death was accidental, the circumstances surrounding it were concerning.

"During the course of the investigation, my inquiries revealed matters giving rise to concern and in my opinion, there is a risk that future deaths could occur unless action is taken," he said.

Mr Stewart has now sent his report to Beccles Medical Centre, which has until 14 August to respond with details about what action it plans to take.

"In my opinion, action should be taken to prevent future deaths, and I believe you have the power to take such action," he added.

Bosses at Beccles Medical Centre, said their "thoughts are with Ms Gregory's family and loved ones at this time".

"We are reviewing the Prevent Future Deaths report and will respond in line with the formal process," a spokesperson added.

"We are committed to working closely with partners to ensure that appropriate actions are taken."

The Black Swan Care Group, which runs Beccles Care Home, was contacted for comment.