Independent inquiry after woman choked to death in disability care home

An independent investigation is being carried out into the death of a resident in a residential centre for people with disabilities, who died after choking on a piece of food in the care home.

Margaret Evans, a 55-year-old woman with an intellectual disability, had been living in a residential centre run by disability provider Sunbeam House Services for 12 years.

An inquest into her death this week found the woman had died after choking on a piece of toast, with staff in the centre and paramedics making unsuccessful attempts to save her life.

Sunbeam House Services runs a number of residential centres for adults with intellectual disabilities, as well as respite and day services. Ms Evans was a resident in its Rosanna Gardens centre in Ashford, Co Wicklow.

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An inquest in Bray Courthouse earlier this week heard that she died on the morning of October 25th, 2021.

Two social care workers in the centre on the day gave evidence to the inquest, which heard that Ms Evans was in bed that morning and asked for a piece of toast to eat. The resident later came into the staff office in the residential centre, they told the inquest.

One of the social care workers described Ms Evans as looking “a bit off-colour”, and said she appeared to be having difficulty “catching her breath”. She then started gasping, before collapsing on the ground, staff said.

The two care workers in the office put Ms Evans in the recovery position and called the emergency services. The staff then started CPR compressions on her until paramedics arrived. The paramedics were unable to resuscitate her, and she was later pronounced dead.

A post-mortem examination of the body found the “presence of small pieces of chewed bread present in the windpipe”.

At the inquest, the coroner asked Sunbeam House staff if any efforts had been made to remove the toast from the resident’s throat after she collapsed. One of the staff said they had not tried to remove the food, but the paramedic tried to do so when they arrived.

The inquest also heard Ms Evans suffered from Parkinsonism as a result of medication she was taking, which would have caused her to have slow movement.

Joe Lynch, chief executive of Sunbeam House, said the organisation expressed “our deepest sympathies to the family involved following this tragic accident last year”.

The disability provider reviewed all incidents in line with Health Service Executive policies, he told The Irish Times.

“We have engaged an independent expert to conduct a thorough review of this tragic accident, and as this review is not concluded, it would not be appropriate to comment at this time,” he said.

Gordon Jeyes, the former chief executive of Tusla, the child and family agency, is carrying out the inquiry. His report is expected to be completed before the end of the year.

Mr Jeyes previously carried out an internal investigation for the organisation in 2018, into allegations of poor practice in one of its centres in Arklow, which found there was an “institutional” approach to care in the facility.