The 83-year-old had been observed earlier that day tearing pages from a magazine and placing them in her mouth
Changes are needed to the protocol used to dispose of used surgical gloves in care homes with dementia patients, a coroner has warned.
It follows the death of 83-year-old Margaret Wilson, who passed away on August 10, 2022, after choking on used surgical gloves she removed from a lidded pedal bin found in a bathroom in Oakridge Care Home. Ms Wilson had a diagnosis of dementia and Alzheimer’s disease and had been living in the care home in Ballynahinch since May 2022.
Earlier that day, Ms Wilson had been found tearing pages from a magazine and placing them in her mouth, with this being the first time she was observed placing foreign objects in her mouth. The 83-year-old was known for wandering the corridors of the care home and was known to be unsettled in the evenings, which is a recognised and common feature of dementia.
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On Thursday, May 7, 2026, in an inquest hearing at Belfast Laganside Court the coroner delivered her findings into Ms Wilson’s death.
The inquest heard from Ms Wilson’s son, Andrew Wilson, who described his mother as a “stalwart” who was “well known and well regarded.” He said the family were satisfied with her care at Oakridge Care Home, and were “generally content” with her placement there.
The coroner heard from Kelly Kilpatrick, the manager of Oakridge at the time, that staffing levels were determined in accordance with guidelines issued by the Regulation Quality Improvement Authority, otherwise known as RQIA.
On the evening of August 10, 2022, there were three staff on duty; one nurse and two healthcare assistants covering the first floor for the duration of the night shift, which began at 8pm.
Healthcare assistant Louise Wilson said she observed Ms Wilson pacing along the corridor shortly before commencing her shift, and became aware she was tearing pages from a magazine and placing them in her mouth. The coroner said Miss Wilson responded to this incident “appropriately,” by reporting the matter to Nurse Badza, who she was on duty with.
The coroner said “it is not clear what steps were taken immediately” by Mr Badza after becoming aware Ms Wilson had been eating pages from a magazine. Mr Badza documented the incident in evaluation sheets, but the coroner found there does not appear to have been a documented review or any assessment of the surrounding environment.
Mr Badza told the inquest there was no opportunity to amend Ms Wilson’s care plan to highlight any risks associated with her ingesting foreign objects, as she had no history of this until the day of her death.
The inquest heard that Nurse Badza later found Ms Wilson leaning on a railing outside the nurse’s station on the first floor of the care home, before he assisted her to a nearby chair, where she “quickly became unresponsive.”
The coroner found he appropriately sounded the emergency buzzer and shouted for assistance from colleagues, prompting the immediate attendance of two care assistants and the nurse on duty on the ground floor. He also contacted emergency services.
Ms Wilson was moved to the floor for CPR, with the coroner accepting that Miss Wilson tilted the deceased’s head back to check her airway and saw a blue item at the back of her throat. Miss Wilson then retrieved what transpired to be a pair of blue surgical gloves, which were used due to the manner in which they were rolled into one another.
Although it isn’t possible to determine exactly where Ms Wilson came by the used gloves, the coroner found “on balance” she is satisfied they were removed from a lidded pedal bin located in a bathroom on the first floor of the care home.
CPR efforts were sustained for a “considerable period of time” with a defibrillator also employed by care home staff. A “do not resuscitate” instruction had been placed on Ms Wilson’s file prior to her placement at Oakridge Care Home, and it was unclear whether this was still present.
However, the coroner found the resuscitation efforts deployed by staff were “appropriate, reasonable, and necessary” in what “cannot be considered a naturally occurring event.”
Following resuscitation efforts by both care home staff and paramedics, Ms Wilson’s life was sadly pronounced extinct at 11.20pm on August 10, 2022. The coroner found her death was the result of asphyxia caused by choking on surgical gloves.
Following Ms Wilson’s death, surgical gloves in Oakridge Care Home are now stored in secure cupboards along the corridors, which can only be opened by a magnetic key. The coroner commended taking this step to reduce risks, however, highlighted that the procedure for the disposal of used gloves “remains unchanged” and they continue to be discarded in pedal bins.
The coroner has called for changes to be made to this protocol, and intends to write to the relevant authorities to highlight this.
She said: “I acknowledge that this is compliant with the applicable regional protocol for waste disposal and is deemed necessary for infection control. However, it is wholly conceivable that such an incident could occur again in the future, whereby a resident in the care home could remove items from a bin and place them in their mouth, which could potentially lead to choking and possible death.
“I therefore intend to write to both the Department of Health and RQIA, including a copy of these findings, with a view to highlighting the risks associated with little pedal bins as a waste disposal system, particularly to patients suffering from dementia, and urge them to consider implementing and utilising a safer method of waste disposal in residential units where patients with dementia reside.”
The coroner closed the inquest by giving her condolences to Ms Wilson’s family.
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