Margaret Wilson tragically died after choking on disposable gloves at Oakridge Care Home in Ballynahinch, County Down, where she had been living
A much-loved pensioner died after choking on disposable gloves at her care home in Northern Ireland, an inquest has heard.
A coroner has now called for changes to the protocol under which used gloves are disposed of in care homes for people with dementia following the tragic death of 83-year-old Margaret Wilson.
Ms Wilson, who had dementia and Alzheimer’s disease, died at Oakridge Care Home in Ballynahinch, County Down, on August 10, 2022, after choking on used surgical gloves she had removed from a lidded pedal bin in a bathroom at the home.
At an inquest hearing at Belfast Laganside Court on Thursday, the coroner ruled that Ms Wilson died from asphyxia, Belfast Live reports.
The inquest heard Ms Wilson had been living at the home since May that year and was known to become unsettled in the evenings – a recognised symptom of dementia.
Ms Wilson’s son, Andrew Wilson, described his mother as a “stalwart” who was “well known and well regarded”. He said the family were satisfied with her care at Oakridge Care Home and were “generally content” with her placement there.
The coroner heard from Kelly Kilpatrick, the manager of Oakridge at the time, who said that staffing levels were determined in accordance with guidelines issued by the Regulation Quality Improvement Authority, otherwise known as RQIA.
On the evening of August 10, 2022, three staff were on duty – one nurse and two healthcare assistants – covering the first floor during the night shift, which began at 8pm.
Healthcare assistant Louise Wilson said she observed Ms Wilson pacing along the corridor shortly before starting her shift and noticed she was tearing pages from a magazine and placing them in her mouth. The coroner said Ms Wilson responded “appropriately” by reporting the matter to Nurse Badza, who she was on duty with.
The coroner said “it is not clear what steps were taken immediately” by Mr Badza after becoming aware Ms Wilson had been eating pages from a magazine. Mr Badza documented the incident in evaluation sheets, but the coroner found there did not appear to have been a documented review or any assessment of the surrounding environment.
Mr Badza told the inquest there was no opportunity to amend Ms Wilson’s care plan to highlight any risks associated with her ingesting foreign objects, as she had no previous history of doing so before the day of her death.
The inquest heard that Nurse Badza later found Ms Wilson leaning on a railing outside the nurse’s station on the first floor of the care home, before he assisted her to a nearby chair, where she “quickly became unresponsive”.
The coroner found he appropriately sounded the emergency buzzer and shouted for assistance from colleagues, prompting the immediate attendance of two care assistants and the nurse on duty on the ground floor. He also contacted emergency services.
Ms Wilson was moved to the floor for CPR, with the coroner accepting that Ms Wilson tilted the deceased’s head back to check her airway and saw a blue item at the back of her throat. Ms Wilson then retrieved what transpired to be a pair of blue surgical gloves, which were used due to the manner in which they were rolled into one another.
Although it is not possible to determine exactly where Ms Wilson came by the used gloves, the coroner found “on balance” she is satisfied they were removed from a lidded pedal bin located in a bathroom on the first floor of the care home.
CPR efforts were sustained for a “considerable period of time”, with a defibrillator also employed by care home staff. A “do not resuscitate” instruction had been placed on Ms Wilson’s file prior to her placement at Oakridge Care Home, and it was unclear whether this was still present.
However, the coroner found the resuscitation efforts deployed by staff were “appropriate, reasonable, and necessary” in what “cannot be considered a naturally occurring event”.
Following Ms Wilson’s death, surgical gloves at Oakridge Care Home are now stored in secure cupboards along corridors that can only be opened using a magnetic key. While the coroner commended this move, she highlighted that the procedure for the disposal of used gloves “remains unchanged” and that they continue to be discarded in pedal bins.
The coroner said: “I acknowledge that this is compliant with the applicable regional protocol for waste disposal and is deemed necessary for infection control. However, it is wholly conceivable that such an incident could occur again in the future, whereby a resident in the care home could remove items from a bin and place them in their mouth, which could potentially lead to choking and possible death.
“I therefore intend to write to both the Department of Health and RQIA, including a copy of these findings, with a view to highlighting the risks associated with little pedal bins as a waste disposal system, particularly to patients suffering from dementia, and urge them to consider implementing and utilising a safer method of waste disposal in residential units where patients with dementia reside.” The coroner closed the inquest by offering her condolences to Ms Wilson’s family.
