Bromley care home staff put man to bed after he choked to death

CARE home staff put a limp and lifeless man to bed after he choked to death on a ham sandwich, an inquest has heard.

A nurse also waited at the wrong entrance for the ambulance and forgot where 79-year-old Noel Pickerin was so he could not be found by paramedics until 11 minutes after they arrived.

The Alzheimer’s sufferer died after having a ham sandwich on May 7 last year at the Bromley Park Nursing Home in Bromley Road, Beckenham, despite his care plan stating he should be supervised when eating.

Former mental health nurse at the home Alexis Collins told an inquest on May 22: “I was not familiar with his food and drink care plan because I worked nights.

“The bit where it says, ‘supervise at all times’, that wasn’t there when I checked the care plan before I gave him the sandwich.

“I don’t know how you prove it but it must have been added in afterwards.”

After giving him the sandwich and walking away Ms Collins became aware he was choking.

She told South London Coroner’s Court: “You get first aid training every so often.

“Did I check vital signs? No…but I think he had a pulse.

“The colour was draining from his face and he was turning white.”

After performing the Heimlich manoeuvre, the 51-year-old went to call the ambulance, she ordered two healthcare assistants to take Mr Pickerin to bed.

One of the carers, Sonia Bartolarai, asked if they should lie him on the floor and perform CPR but Ms Collins did not respond.

When asked if she should have acted on her instinct, Ms Bartolarai said: “We could not overrule her. If she says he is alive, who am I to say he is not.”

She admitted he was “limp and lifeless” as they took him to bed and put him in pyjamas.

Paramedics were called at 9.10pm but were not able to enter until five minutes later because Ms Collins was waiting at a different entrance and it took another six minutes for them to find where Mr Pickerin was.

London Ambulance Service paramedic Gareth Landen said: “The nurse seemed very flustered – we were stuck outside for a while and then she couldn’t remember his room.

“It took 11 minutes between getting to the home and finding the patient.

“He was in bed with the covers up to his chest and looked waxy. It was obvious he was deceased.

“I would not expect to see someone in that position in a care home, I’d have thought they would be on the floor and CPR would be performed.

“However even if we had got to him earlier, I don’t think we could have saved him because the food was so far down.”

The cause of death was given as asphyxia with upper airways obstruction and impacted food bolus with secondary causes cited as dementia and Barrett’s Oesophagus. Dr Palmer recorded death by accident.

Care home manager Jackie Hayward-Grant said she had carried out all statutory checks when recruiting Ms Collins and confirmed the nurse had been subject to a disciplinary procedure before relating to a diabetic patient.

Ms Hayward-Grant said: “The supervision instruction for Mr Pickerin’s care plan was not added in after.

“It was written on March 30 when the rest of the report was.”

She confirmed procedures had been improved at the care home to prevent similar situations happening again and Ms Collins was suspended following the incident.

However she continued to work some shifts in a nursing home until she was given an 18 month Interim Suspension Order by the Nursing and Midwifery Council (NMC) in March this year – 10 months after Mr Pickerin had died.

However Ms Collins is still able to work as a healthcare assistant because this role is not regulated by the NMC.

Bromley Park Nursing Home declined to comment on the case.

Mr Pickerin’s family want the care industry to be reformed so these situations do not happen again.

Daughter Andrea Pickerin, who attended the inquest, said: “It is not the care home itself, it is more the industry which needs to be improved and better regulated.

“There need to be the same safeguards there are in children’s care which has much higher standards.”