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