Peter Dickens, 31, had autism and severe learning disabilities
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.
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 quicklyOn January 22, 2022, Mr Dicken's airway became obstructed while eating a sandwich. He later died at Bassetlaw Hospital.
"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 Dicken's death.
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".
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