FAI concludes death of elderly woman in care home by choking could have been avoided with greater supervision

About this case:

• Citation:
  [2025] FAI 46
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff C A Walls

Anne Amos, a resident in the Pine Villa Nursing Home in Loanhead, died aged 72 on 13 September 2021 after choking on a piece of toast she had failed to swallow. Mansfield Care Ltd, the owners of the home, participated directly in the inquiry, arguing that not enough was known about the circumstances of the death to allow the recommendations supported by the Crown.

The inquiry was conducted by Sheriff Charles Walls at Edinburgh Sheriff Court. The Crown was represented by Ms Stewart, procurator fiscal depute, and Mansfield Care by Mr Henry, advocate. The family of Mrs Amos attended the inquiry as observers.

Rarely looked at folders

Mrs Amos was diagnosed with frontotemporal dementia in 2016. Following a decline in her condition in 2021, she was assessed by Midlothian Council as requiring 24-hour care and was admitted to Pine Villa. At the time of her admission, she was non-verbal and taking various prescribed medications. An Eating and Drinking Care Plan completed for Mrs Amos in August 2021 indicated that she required close supervision and some assistance. In an affidavit, one of her daughters explained that sometimes she would store food in her cheeks and require prompting to wash it down.

On 10 September 2021, Mrs Amos was recorded as developing a UTI or chest infection, and tested negative for Covid-19. On the morning of her death, her care needs were met by two care assistants. One of them, Diane McIntyre, gave her toast and a cup of tea and left her alone in her room. When she returned, Mrs Amos was sitting in her chair unresponsive, with life pronounced extinct at 12:15pm.

A final postmortem report in February 2022 confirmed that the causes of death were choking on food, Alzheimer’s disease, and atherosclerotic cardiovascular disease. At the time of Mrs Amos’ death, Pine Villa had paper records for all residents contained in a folder in the dining room. However, there was no system whereby information regarding residents was shared formally with staff, and employees’ evidence was that they rarely looked at the folders and relied on information shared verbally between staff.

An expert instructed by the Crown, Ms Lazenby-Paterson, explained that frail older adults were more likely to experience dysphagia and choking because their swallowing mechanism could not compensate for added stresses of comorbid conditions. For the Crown it was submitted that a requirement for supervision would have realistically resulted in Mrs Amos’ death being avoided, and the pre-admission proceeded did not appropriately deal with the risk of choking, being more concerned with what foods the admitted person liked or disliked.

For Mansfield Care it was submitted that the cause of accident remained unknown, as it was not known what had caused Mrs Amos to choke on her food. In respect of findings under section 26(2) of the Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016, a causal aspect was required. There was insufficient evidence here about the effect the precautions identified would have had.

No adequate system

In his determination, Sheriff Walls said of the cause of the accident: “Notwithstanding the discrepancy between the evidence of Ms Holmes and Pine Villa witnesses regarding what was or was not said about supervision and choking, it is abundantly clear from the evidence that Mrs Amos ought to have been supervised when eating. Pine Villa had determined that Mrs Amos should be supervised but failed to ensure that this was done. However, the expert evidence of Ms Lazenby-Paterson was that choking can happen to anybody and could occur even under close supervision.”

He continued: “If the accident which caused death was choking, there was no evidence to allow me to determine the cause of choking. Accordingly, I am unable to make a finding under this section. During the hearing on submissions, the Crown initially suggested that a further cause of choking was Mrs Amos being given toast, which it was submitted was a risky food for someone with Alzheimer’s and that she ought to have been fed alternative, softer foods. Ultimately, the Crown did not insist on this submission as it was not supported by any evidence.”

Considering whether any precautions would realistically have resulted in death being avoided, Sheriff Walls said: “There was no medical evidence regarding how long a person takes to die from choking, or how long Mrs Amos specifically may have taken to die. However, it is reasonable to infer that in a nursing home setting, supervision might realistically have avoided death from choking, when nursing assistance was available and could have been sought promptly by whoever was supervising Mrs Amos.”

He added: “I am satisfied on the evidence 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. This was a defect in the Pine Villa system of work which contributed to the death.”

Sheriff Walls therefore recommended that a choking policy be put into place at Pine Villa to identify and manage symptoms of dysphagia, to be accompanied by additional pre-admission questions designed to identify potential choking risks. It was noted that a digital system had since been implemented to allow staff to access resident information using a handheld device, and therefore no recommendations were made in respect of the sharing of information between staff.