Home 'neglected' vulnerable autistic Nottinghamshire man who died after choking on sandwich

Staff at a Nottinghamshire residential home failed to follow vital guidance before a vulnerable man with severe learning disabilities died after choking on a sandwich. Peter Dickens, 31, whose risk of choking was known and an "imminent risk to his life" died in January 2022 while living at the Beeches near Retford.

An inquest found neglect in his care contributed to his death. Cygnet Healthcare said it had made "significant improvements" since his death.

Mr Dickens, who moved into the Beeches in February 2021, was the subject of a Deprivation of Liberty Safeguard due to having autism and severe learning disabilities. This meant he required full one-to-one support for all his needs, including at mealtimes to prevent him over-filling his mouth and eating too quickly

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On January 22, 2022, Mr Dickens' airway became obstructed while eating a sandwich. He later died at Bassetlaw Hospital.

Elizabeth Didcock, the assistant coroner who oversaw an inquest into his death at Nottingham Council House, said his Eating and Drinking plan was not followed on the day, directly leading to the choking incident that led to his death.

"His risk of choking was known and was a real and imminent risk to his life- he had had previous known episodes of life threatening choking," she said. It was not the first time the guidance had not been followed, with Ms Didcock pointing out there had been non compliance "many times" prior to the day of Mr Dickens' death.

She also said there was a lack of oversight of compliance by managers and multidisciplinary team staff at the home. "All these omissions in care made a more than minimal, negligible, or trivial contribution to his death. Peter's death was contributed to by neglect," she said.

Ms Didcock wrote a Prevention of Future Deaths report following the conclusion of the inquest on March 28. She said there "remains a lack of understanding by Beeches management of the reasons for the lack of compliance" and added she was "not reassured that necessary actions to address these serious issues identified are in place".

Cygnet Healthcare has until July 2 to respond with an action plan to the coroner. A spokesperson for the company said: "We would like to express our deepest condolences to Peter’s family and all those who continue to be affected by his loss.

"We are in the process of giving our response to address the coroner’s concerns but can offer our full reassurance that we have made significant improvements following Peter’s death, including strengthening staff compliance with Eating and Drinking guidelines and sharing best practice in managing choking risks, dysphagia and nutrition and hydration.

"We take our responsibilities to provide safe care extremely seriously and always seek to ensure lessons learned are identified and shared and that improvements are addressed and embedded. Our service users are at the heart of all we do and our thoughts remain with Peter’s family."