Overview

• Senior Coroner Andrew Hetherington concluded that 88-year-old Joan Whitworth died after choking on a meal prepared in violation of her prescribed diet plan
• The Prevention of Future Deaths report identifies six matters of concern—five for Hillcare’s Oaks Care Home operator and one for the NHS trust’s speech and language team
• Investigations revealed that staff relied on verbal handovers, failed to use referral forms or direct observation for speech and language assessments, and lacked up-to-date basic life support and first aid training
• Emergency protocols broke down when a nurse misinterpreted do-not-attempt-CPR policies and resuscitation equipment was unavailable, preventing timely CPR
• Both the care home operator and Northumbria Healthcare NHS Trust have acknowledged the coroner’s findings and launched internal reviews ahead of their formal responses due within 56 days