Wood Hill Lodge: Sheffield care home did not attempt CPR on woman believed to be choking, inquest hears

Sheffield care home staff who found a woman passed out on her bathroom floor, thought to be from choking, did not attempt CPR due to "oversight," an inquest has heard.

Jacqueline Crapper, who suffered from dementia, died in Wood Hill Lodge care home in May, aged 78.

The possibility of her choking was not mentioned on the 999 call, which resulted in a slower ambulance response and CPR not being performed.

An ambulance could have been there in less than five minutes if choking had been mentioned, but instead took slightly over two hours, the court heard.

James Goulding, Yorkshire Ambulance Service's clinical response and governance manager, said: "This was not due to error or lack of resource. I have really struggled to find out how anyone would have picked up on the choking on the call.

"There is nothing that I realistically could have expected anyone to pick up on from our end. I'm really sorry."

The call was assessed by independent "blind" auditors, who also did not pick up on any suggestion that Jacqueline may have choked.

Mr Goulding added: "If we had known, we would have been on a completely different protocol. It would not have dropped below a Category 1."

Nike Mohammed, a nurse at Wood Hill Lodge, made the emergency call and was walking around, in and out of her room, throughout.

He said: "There was a lot of people around, so I couldn’t see anything when I came back in … the back slaps that took place were never mentioned to me.

"I just told them to leave her alone [not attempt CPR]."

Mr Mohammed told the call handler he was "certain" Jacqueline should not be resuscitated, due to a Do Not Resuscitate (DNR) being in place.

But for potentially reversible emergencies, such as choking or anaphylaxis, CPR should be done regardless.

Mr Goulding said this fact is "well-understood" by ambulance staff.

"If we knew it was a choking, the DNR would not have been accepted," he said.

Matthew Fordham, formerly the deputy manager at Wood Hill Lodge, gave three back slaps to Jacqueline in the bathroom before moving her to her bed with other staff.

He tried to remove what looked like nuts from around her tongue using his fingers, and then with a plastic spoon.

Mr Fordham said: "I cannot remember communicating about the nuts [to Mr Mohammed]. I thought people around me could see what I was trying to do.

"I was following advice from the ambulance to not do CPR."

The coroner, Mrs Katy Dickinson, questioned whether he knew the DNR did not apply, to which he simply said: "Oversight, I'm sorry."

Wood Hill Lodge was recently rated "inadequate" by the CQC, and could face closure if it does not improve.

Linda Meston, managing director of the care home’s owner, Portland, said the investigation report for this incident was "not of the expected standard".

She said: "Witness statements were obtained by [the former operations director], but we don't know where they are. I even went into his company emails, but couldn’t find them anywhere.

"I was not told about the incident at the time. He should have told me."

Since the CQC rating, Wood Hill Lodge has introduced scenarios training, new emergency call procedures, and choking-specific first aid training for all staff.

Samantha Hukin, Jacqueline's daughter-in-law, said these improvements have "come at a cost".

Jacqueline had only been at the home for two months before her passing on May 16.

Ms Meston, who is a qualified nurse, said: "I think some of the evidence we got today was due to a limited understanding of what choking looks like.

"The picture I'm being shown doesn't fit well with choking. My feeling is that there has been something else that has caused this."

Ms Hukin, who is also a nurse, said she agreed.

When Jacqueline was found in the bathroom, she had been incontinent, something which the court heard had never happened previously.

When her family members arrived at the home, and went to move her body to the bed, the mattress was "soaked through", Ms Hukin told the court.

She said: "This is more than an error. That's my mother-in-law, that's Lesley's mum.

"Jackie was a very family-oriented woman. She idolised her kids, Lesley, Allen and John. She were a great cook as well - her Sunday roasts were the best.

"The week before she passed away, she was at Lesley’s, and she was dancing, and she had a plate of food in front of her.

"We just think there could have been more care given to Jackie in those final moments of her life."

Mrs Dickinson did not conclude the inquest yesterday (January 23), wanting to get a second medical opinion on the cause of death.

It was listed initially as choking, with an underlying cause of dementia.

The inquest is expected to conclude at Sheffield Medico-Legal Centre on February 27.