Bipolar woman at Gosport War Memorial Hospital died 'by misadventure' after choking on cake wrapped in plastic, inquest hears
An inquest into the death of a bipolar woman has heard how she choked on a piece of cake after it was served to her in its plastic wrapper.
Fenella Esson, who suffered with severe bipolar affective disorder, was detained at Gosport War Memorial Hospital under Section 3 of the Mental Health Act 1983 in July 2020 after experiencing worsening confusion and hallucinations.
A five-day inquest, which took place at Winchester Coroners Court between April 7 and 11, heard how the 66-year-old died after choking on a slice of cake in its plastic wrapper.
HM Senior Coroner Chistopher Wilkinson noted that, although it was unlikely to have caused or contributed to Fenella’s death, steps should be taken to improve communication between hospital trusts to ensure faster arrival of appropriate emergency care in future scenarios.
She then proceeded to put the cake, and the wrapping, into her throat causing her to start choking which resulted in her losing consciousness and going into cardiac arrest.
Nursing staff outside her room rushed in when they heard Ms Esson coughing considerably and they attempted to administer back slaps and abdominal thrusts, both of which were unsuccessful.
The inquest heard how emergency services were contacted, but the ambulance was initially dispatched as a category 2 call, rather than the highest-priority category 1.
Nursing staff at the hospital started CPR when Ms Esson lost consciousness but the court heard from an expert emergency medicine consultant who said that, in his opinion, ‘the quality of CPR received by Ms Esson was poor’.
This comes after a paramedic reported finding staff conducting one-handed compressions while standing, which the paramedic considered to be ineffective.
Upon arrival, the first paramedic removed the plastic-wrapped cake from Fenella’s airway using forceps before she was transferred to Queen Alexandra Hospital in Portsmouth.
An emergency medicine expert concluded that Fenella’s chances of survival would have remained very low even if the CPR had been of ‘optimal quality’, and the emergency response had occurred within the most ‘optimal timeframe’.
The court reached a conclusion that Ms Esson death by misadventure and the coroner noted potential areas to improve in a bit to minimise the risk of future deaths.
Fenella’s brother, Matthew said: “I would like to thank the coroner for his forensic attention to detail, thoroughness and also for his sensitivity and compassion.
“It was also gratifying that the coroner was prepared to look at issues outside the immediate facts of the case, specifically the poor quality of communication between the Trust and Fenella's family, evidenced well by the failure of the Trust to acknowledge my sister's death, which I felt was not only insensitive, but discourteous.
“This omission, it transpired, was due to an administrative error, which caused her death to be categorised as an 'incident of low harm'. Thankfully, following assurances from the Trust's Chief Executive, this sort of error is unlikely to be repeated.”
Sharon Craddock, head of nursing, professions & quality at Hampshire and Isle of Wight Healthcare NHS Foundation Trust, said: “We offer our heartfelt condolences to Fenella’s family. This was a tragic incident and we recognise the impact it has had on everyone who knew her.
“We will always consider opportunities for learning in situations such as these and have taken steps to strengthen staff training and enhance how we work with partner organisations in urgent situations.
“We are undertaking further joint work in this regard following reflections made by the coroner at the inquest in order to support continued improvements in patient safety.”