Anne Amos, 72, passed away on September 13, 2021 after choking on food at Pine Villa Nursing Home in Loanhead.
A pensioner who died at a Scots care home after choking on food should have been supervised while eating, a Fatal Accident Inquiry has ruled.
Anne Amos, 72, passed away on September 13 2021 at Pine Villa Nursing Home in Loanhead. Ms Amos had been receiving round the clock care at the facility in Midlothian after being diagnosed with dementia.
A FAI into her death heard that it was no longer possible for family and carers to provide the level of care that she required at home safely. At the time of her admission to Pine Villa, she was non-verbal due to the progression of her condition.
Shortly after her arrival, staff at the care home completed an eating and drinking care plan for Mrs Amos. This plan indicated that when eating, Mrs Amos “required close supervision e.g. in small groups” and “required some assistance.”
The plan also recorded that Mrs Amos “needed support/prompting/encouragement but could also feed herself at times.”
On the day of her death, Ms Amos had been given toast and a cup of tea and left her alone in her room. When workers returned, she was found unresponsive and later pronounced dead.
Her cause of death was confirmed as choking on food, Alzheimer’s disease and Atherosclerotic cardiovascular disease. The FAI, held by Sheriff Charles Alastair Walls at Edinburgh Sheriff Court, ruled that the precaution of supervision of the care home resident while she was eating could reasonably have been taken to prevent her death.
It further found that there was no adequate system whereby important information about residents’ care needs was shared with staff, and in particular the identified requirement for Mrs Amos to be supervised while eating. Pine Villa had determined that Mrs Amos should be supervised but failed to ensure that this was done.
Mansfield Care – the owners of Pine Villa Nursing Home – have since introduced a digital system where each staff member has a handheld device which contains key information on each resident. Given that the system of recording and sharing residents’ care needs – which was in place at the time of Mrs Amos’ death – has been replaced, there were no recommendations laid out by the Sheriff.
However, as no changes were made to the admission process at Pine Villa or the establishment of a choking policy, the Sheriff recommended that a strategy be put in place to identify and manage symptoms of dysphagia and the risk of choking. Unlike a criminal trial, an FAI seeks to establish the facts surrounding the death and is not a hearing which apportions blame.
The purpose of an inquiry is to establish the circumstances of the death and to consider what steps, if any, may be taken to prevent other deaths in similar circumstances.
Following the publication of the determination, Procurator Fiscal Andy Shanks, who leads on fatalities investigations for COPFS, said: “The Sheriff’s determination makes detailed recommendations for care home staff on the management of the risk of choking.
“The discretionary FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Mrs Amos’s death were presented in evidence. My thoughts remain with her loved ones at this difficult time.”
