Stephen Dulling: York Hospital criticised after patient died "choking on piece of toast"

Stephen Dulling, 69, was admitted to the hospital’s Acute Medical Unit in August last year.

He was living with Parkinson’s Disease and dementia, and had problems with his swallowing.

But staff did not change his dietary needs in light of his condition, and he wasn’t given a food chart for them to keep track of what he was eating.

Three days later on September 2, he went into cardiac arrest after choking on his breakfast. He died on September 4 at the hospital.

Area coroner Catherine Cundy has written to the hospital demanding it sets out how they will prevent future deaths like Mr Dulling’s.

She wrote: “During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.

“I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital.”

Ms Cundy said Mr Dulling’s wife had not been asked about his dietary needs by hospital staff, that it was recorded that he could eat a normal diet, and that there had been no assessment or escalation of Mr Dulling’s refusal of intravenous fluids.

She also said there was Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;

This constituted a “series of lapses in basic nursing care,” she said.

A spokesperson for York and Scarborough Teaching Hospitals NHS Foundation Trust, said:

“The Trust would like to convey sincere condolences to Mr Dulling’s family. We recognise and share the concerns raised by the HM Coroner. Following the conclusion of the inquest we appreciate that the coroner wishes for us to take further steps, and we fully take that on board.

“We will be setting out our action plan and implementation timetable to meet the coroner’s deadline. The Trust takes patient safety seriously and endeavours to ensure lessons are learned.”