Grandfather with dementia tragically dies after care home staff fail to follow vital instructions

In a deeply distressing incident that has raised serious concerns about the standard of care in some aged care facilities, a grandfather with dementia tragically choked to death on a chicken nugget after two care home staff failed to follow vital instructions to cut up his food.

The inquest into the death of 75-year-old Bob Buckley has revealed a series of failures that culminated in a preventable loss of life, leaving a family grappling with grief and unanswered questions.



Bob Buckley, a cherished family man, was residing at The Chase care home in Canterbury, where he required specialist care due to his dementia and known risk of choking.

His condition necessitated that his food be cut into small pieces and that he be closely monitored while eating.

However, on the fateful day of 11 August 2019, these crucial precautions were overlooked, leading to a catastrophic outcome.


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Bob Buckley tragically choked to death after two care home staff failed to follow instructions on cutting up his food. Credit: Shutterstock


The inquest heard how Bob was known to 'pouch' his food in his mouth and eating quickly—behaviours that significantly increased his choking risk.

These concerns had been communicated by his wife and were well-documented in the care home's risk assessment.

Despite this, Bob was served whole chicken nuggets and half a baby carrot, which he was unable to safely consume.

When Bob was found choking, staff attempted to dislodge the food using back slaps and a 'thrusting' technique, but their efforts were in vain.

Paramedics arrived swiftly, but due to a do-not-resuscitate order, they did not attempt revival.



The coroner, Ian Brownhill, said, ‘The food was not cut into small pieces, and paramedics were surprised at the size of the food removed from Bob's airway.’

The court identified two carers who were implicated in the events leading to Bob's death.

'”Carer one” handed Bob the plate of food at tea time. She also plated the food, which he ate,’ Brownhill said.

'She previously said the plates were pre-prepared, but this does not accord with what she told police after his death.'

Meanwhile, 'Carer two' was supposed to supervise him as he ate, but 'Carer two' left Bob and other residents unsupervised.

'She was walking up and down in the lounge when Bob was choking,’ Brownhill said.

The coroner concluded that the care home breached its duty of care and recorded a narrative conclusion of neglect.

Bob's step-daughter, Lisa Parrott, spoke of the profound guilt and pain the family has endured, exacerbated by the care home's lack of communication and apology following the incident.



The family's ordeal was prolonged by a five-year wait for the inquest's conclusion, during which criminal charges against a staff member were ultimately dropped.

The revelation that Bob had been given whole chicken nuggets, contrary to initial reports of choking on birthday cake, added to the family's anguish.

'It was only two years later after another visit from [healthcare watchdog] Care Quality Commission, that management left, and positive changes seem to have been made,’ Lisa said.

'It was shocking to find out the actions, or should I say inactions, that led up to Bob's death, but what made it worse was finding out what happened afterwards.

'Five years after Bob's death, no one from the home has ever contacted mum and apologised after that initial call to tell her what happened.

'How heartless is that?’



In the aftermath of Bob's death, The Chase care home underwent scrutiny by the Care Quality Commission (CQC).

Five days after Bob’s death, the CQC rated The Chase as ‘inadequate’. It was put into special measures in 2021 and moved up to ‘requires improvement’ after an inspection in April 2022.

'We acknowledge the coroner's findings and would like to offer our sincere condolences and apologies to Mr Buckley's family for their loss,’ The Chase care home said.

'Due to the ongoing investigations, which have now concluded, we have been unable to comment on this matter previously.’

'Since Mr Buckley's death, a new management team has been put in place. We have implemented a number of new policies and procedures, specifically in relation to the management of risks around diet and nutrition and all staff have received further training.’

'A further inspection was carried out at the home by the CQC in May 2023, and the home was assessed to be “Good” in “safe” and “well-led”.’

'We remain fully committed to maintaining this high standard of care to ensure the health, safety and wellbeing of our residents at all times in the future.'
Key Takeaways
  • Bob Buckley, a grandfather with dementia, choked to death on a chicken nugget after care home staff failed to cut up his food as required for his safety.
  • The care home, The Chase in Canterbury, had prior knowledge of Mr. Buckley's choking risk but neglected to provide the necessary supervision and care.
  • An inquest into his death concluded with a narrative finding of neglect, highlighting failures in mitigating his choking risk by not cutting his food or monitoring him closely.
  • The Chase care home has since undergone management changes, implemented new policies and training, and received an improved rating from the Care Quality Commission following the incident.
Our thoughts go to Bob Buckley and his family.

Have you or someone you know encountered similar issues with aged care? How did you address them, and what advice would you give to others in similar situations? Let us know in the comments below.
 
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My aunt had alzheimers and was only allowed thickened liquids for this very reason. They asked me to feed her these and eventually I said no because of the choking possibility. I said to the nursing home it was their job and if anything happened I didnt' want it on my watch. They had too few staff and were asking relatives to feed their family members. Not a good situation when she paid a fortune to get into the aged care/nursing home. It does happen here in Australia.
 
Do not resuscitate to me means if my heart stopped don’t try to bring me back
But if I’m choking for god sake help me clear my air way. I don’t get it to me that’s not resuscitate.
I think it was the Paramedics who complied with a 'do not resuscitate' order.

The article is silent but it is likely that the man was unconscious by the time the Paramedics arrived.
 
1727846578717.pngThe aged care food standards are very clear and worldwide, there is no excuse for these standards not to be adhered too. I suspect the staff member was ill informed, possibly a casual or not given a proper handover. Nursing staff should not be serving food.
 
View attachment 59873The aged care food standards are very clear and worldwide, there is no excuse for these standards not to be adhered too. I suspect the staff member was ill informed, possibly a casual or not given a proper handover. Nursing staff should not be serving food.
I don't think Nursing staff do. That's probably why the article says Carer One and Carer Two.
 
I don't think Nursing staff do. That's probably why the article says Carer One and Carer Two.
Thats what the carer is, a nurse with a few less qualifications. The career takes care of personal care, showering , toileting, assisting to feed a client who is not capable. Kitchen staff should be fully trained to produce and serve the correct food requirements to residents.
 
Unfortunately, lets face facts, the facilities are extremely quick to take your dough and have it banked before you can say "Jack Robinson". They then promise the family the world of care for their loved one. When the family leave with aspirations of assurances of good welfare, then the reality kicks in. They don't give a shit. 99.99% of requests are disregarded by the same percentage of staff.

Sorry about that, but it's my thoughts on what families talk about.
 
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Chicken nuggets and half a baby carrot :rolleyes: ………..This man should not have died….Two people did not do their jobs for whatever reason you want to believe…..When someone is choking and can’t be helped, eventually the person will pass out….The body relaxes and it should be relatively easy to get the item from his throat, then he can breathe again. However, if the item is too far down or if he wasn’t found in enough time then oxygen can’t get through, he can’t breathe, he dies….The paramedics might not have arrived in enough time to save him from brain damage caused by lack of oxygen, in which case4 the DNR would have been used……I only know of a very few people who have had to live their last days in a care home, and it was always sad to visit them because you’ve had meals and drinks and happy times before their mind got all muddled, and none of them lived for more than a couple of years, if that……..Yes….sad :confused:
 
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Reactions: natalielocket
Falls are another story in aged care. You will rarely find out the truth. My father fell and it took
Three days to decide he had a fractured hip. We took
Him out of this nursing home, but was not treated any better in a Victorian hospital. Always makes me weep
 
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Reactions: natalielocket
My aunt had alzheimers and was only allowed thickened liquids for this very reason. They asked me to feed her these and eventually I said no because of the choking possibility. I said to the nursing home it was their job and if anything happened I didnt' want it on my watch. They had too few staff and were asking relatives to feed their family members. Not a good situation when she paid a fortune to get into the aged care/nursing home. It does happen here in Australia.
It certainly does, and not many people (working in Nursing homes, or community) aren`t trained to deal with people with any kind of Dementia. Some Nursing homes and Community Care Organizations hire untrained staff as they are cheaper. It is going to be a long haul for any Government to overhaul the Age Care System. There have been complaints for years about the system and if it wasn`t for the National Seniors and COTA organizations, advocating for the change in the system, it would still be ongoing.
 
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Another tragic story in aged care. I truly don't understand why these tragedies keep happening. Well l do know. Why do some people who work in aged care even apply for the job they should not be there no care.
Kind regards Vicki
So true. Not trained and it is just a job. I loved working in Age Care, now 75, but retired last year fully, due to having to work with untrained staff who didn`t care, and a Supervisor who would `Look into it`.
 
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Reactions: Liz

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