A 23-YEAR-OLD died after food got into his lungs while he was fed at supported living accommodation, a coroner ruled yesterday.

Oxfordshire Coroner Darren Salter recorded a narrative verdict into the death on August 22, 2012, of Nico Reed, who lived at Barrantynes, a home in Chalgrove for people with complex needs.

The court heard Mr Reed was previously cared for at the Penhurst School in Chipping Norton but was transferred to Barrantynes in 2011 to move to an adult care package after an assessment by Oxfordshire County Council.

Susan Martin, a clinical co-ordinator for physiotherapy with Southern Health NHS Trust at the time of Mr Reed’s death, gave evidence at the inquest.

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She said risk assessments were in place for choking but none were written on dealing with the spasms that Mr Reed suffered from, or for the risk of aspiration (when regurgitated food gets into the airway and lungs).

However, she added there were clinical plans in place for dealing with these risks and staff had been given sufficient training.

At Barrantynes, Mr Reed was mainly fed through a peg tube while propped up in bed at a 45 degree angle.

He was prone to morning vomiting, which could sometimes cause food to go into his lungs, and also prone to muscle spasms, which could cause him to extend his neck and turn his head in a way that could stop him breathing for up to ten seconds. Mr Reed was last fed through the tube at about 8pm on August 21.

An overnight carer who had three other patients to look after checked on him throughout the night.

In his narrative verdict, Mr Salter said Mr Reed had died of “aspiration of gastric contents” with an “underlying cause of cerebral palsy”.

He said Mr Reed had last been checked at about 5.15am by carer Weston Mickeke who noted he was breathing and was reclined at about 45 degrees in his bed.

When Mr Mickeke returned between 45 minutes and an hour later he found Mr Reed unresponsive and ambulance crews were called. Mr Reed was taken to the John Radcliffe Hospital, in Oxford, but was pronounced dead.

Mr Salter said: “There was no specific risk assessment for early morning vomiting but there were detailed care plans which do refer to vomiting and to the risk of aspiration and I am satisfied that most of the staff were aware of Nico’s vomiting and the risk of aspiration.

“In regard to the number of checks, 20 minutes is what is stated in the care plan and I accept that this is intended to be a guideline and it’s almost bound to be [just a guideline] given that there was one member of night-time staff.”

Southern Health now owns Barrantynes after the acquisition of previous owner the Ridgeway Partnership.

Mr Salter said he would not be writing a report to it because he did not believe there was a risk of future deaths at the facility.


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