Failings over man who choked to death on ward
Mother calls for medics to ‘learn lessons’ from tragedy
THE mother of a Black Country man who died after choking on his own vomit has revealed her heartache after “failings” in her son’s care were uncovered.
Dawn Williams is calling on medics to learn lessons after her son Daniel Turner, 34, died while on a locked high-dependency mental health ward.
Mr Turner, who had a history of mental health difficulties including paranoid schizophrenia, was discovered with his airways blocked, despite being under 15-minute observations at the Birmingham mental health facility.
Ms Williams said: “It’s been almost a year since we lost Daniel but I still struggle every day to come to terms with him no longer being here.
“He suffered with his mental health for a long time but we believed he was in the right place to get the help and support he needed.
“It was heartbreaking when we were told he had died. It’s been particularly difficult for me to face losing my first-born son as a parent should never have to bury their child.”
Mr Turner was detained under the Mental Health Act at Erdington’s Endeavour Court, run by Birmingham and Solihull Mental Health Foundation NHS Trust, in September 2020.
He had spent most of the evening of November 28 in his bedroom and was asleep, breathing normally at 1.03am, court documents revealed.
But staff later discovered he was having difficulty breathing and making gurgling sounds but he failed to respond to his name being called, forcing them to activate an alarm at 1.21am.
They started CPR and called paramedics at 1.25am. The first paramedic arrived at 1.34am, with more arriving five minutes later.
Mr Turner, who was on anti-psychotic medication, remained unresponsive and was pronounced dead at the scene just after 2am.
A Birmingham Coroner’s Court jury concluded Mr Turner died as a result of aspiration of gastric contents while lying down. His position and reflux contributed to his death, jurors concluded.
Ms Williams added: “The inquest was really tough on us all, having to relive what Daniel went through, but we are grateful to finally have some answers.
“All we hope for now is that something is learned from our loss to stop others from going through the pain and suffering we have.”
The inquest heard about a number of failings in Mr Turner’s care by staff in Endeavour Court, lawyers at Irwin Mitchell said.
This included evidence of poor communication about a previous choking incident in August on another ward, which was mentioned in inpatient notes but not in a risk assessment summary.
It meant Mr Turner was not referred to a speech and language therapist and nursing staff had not discussed the previous incident or even read his clinical records.
Two employees were on a break at the same time which reduced medics on duty at the time of his death.
The ward did not have a cordless phone so staff were unable to take the phone to Mr Turner to follow instructions from 999 operators.
The trust launched an probe and recommendations included installing swipe locks and improved planning of breaks.
A trust spokesman said: “We have undertaken a thorough investigation and are implementing the recommendations of that investigation.”