Goodmayes Hospital makes changes to dining policy after patient dies from choking on chicken and chips

Dawn Jenkins, who was born in King George Hospital and lived in the borough with foster carers, died on May 12 last year aged 50 at the hospital in Barley Lane, which is run by the North East London Foundation Trust (Nelft), Redbridge's mental health care providers.

Dawn suffered from learning difficulties and mental health problems and was placed in the care of Goodmayes Hospital at the end of 2017 when her physical and mental wellbeing began to deteriorate.

She had already been an inpatient at the hospital in 2004, 2012 and 2015, a jury at Walthamstow Coroner's Court heard during a four-day hearing.

On May 10, 2018, two days before her death, while under one-to-one supervision, she was eating takeaway chicken and chips, her meal of choice, when staff noticed her "going pale in colour".

They realised she was choking and called for assistance.

Paramedics were called although the first attempt to get through to the London Ambulance Service control room was delayed because a mobile phone lost signal.

When medics arrived they removed the obstruction and carried out CPR before she was taken to King George Hospital and admitted to intensive care.

She died two days later, on May 12, 2018.

On the final day of the hearing yesterday (Thursday, June 6), the jury foreman revealed their conclusions in full.

He said: "Dawn Jenkins died from a hypoxic brain injury as a result of choking, in part because the risk of choking was not managed."

He added: "The trust failed to prepare food to minimise the risk of choking."

The jury had also found that, once Dawn started choking, there was "no clear clinical leadership and a chaotic response".

However, they had concluded that, on the balance of probabilities, there was no evidence that a different or quicker emergency response could have saved her life.

Senior Coroner Nadia Persaud thanked the jury for their findings, and took time to praise Dawn as "an extraordinary woman who touched everyone that she met."

At the inquest's conclusion, she deemed it was not necessary to file an official Prevention of Further Deaths report on the incident.

She told the court: "I am satisfied that the trust has taken Dawn's death very seriously indeed.

"Since Dawn's death they have done everything they reasonably could do to minimise the risk - you can never eradicate the risk entirely - of a similar incident ever occurring again."

Dawn, who grew up on the Broadmead Estate in Woodford Green before moving to Gants Hill, volunteered with young children and Lee said staff really valued her contribution.

She enjoyed meeting new people and was able to make friends easily, and she loved watching Disney movies.

"She was a real chatterbox when you got know her," her brother Lee said in a statement.

He said Dawn was a caring person who always wanted to help people and she had "a heart of gold"

"Her cheeky sense of humour was hilarious," he said. "Those who knew Dawn had a true friend for life."

Giving evidence to the jury, Dr Shazia Zahid, the consultant psychiatrist at Goodmayes Hospital, said Dawn was under "one-to-one observations" at the time of her death - meaning someone had been watching her at all times.

Dr Zahid had identified that Dawn was suffering 'mixed affective disorder' - she would experience both depression and mania.

One month before Dawn's death, on April 9, she was taken to King George Hospital A&E after staff questioned whether she had swallowed beads from a bracelet, the inquest heard.

Ms Persaud questioned how the incident had occurred while under close supervision and Dawn's family asked whether she should have been put under increased observation afterwards.

Dr Zahid said she reminded staff to observe her behaviour more closely after the incident.

She added that there was no "acute concern" that Dawn was not eating well, but she did eat slowly.

"She would hold onto her food and take her time eating it. There were no concerns about her rushing her food," Dr Zahid told the jury.

A note in Dawn's 2012 care plan said she "should be monitored closely during meal times" and staff might need to give her assistance, the inquest heard.

Dr Zahid said: "I was not informed of any concern around eating or drinking or chewing."

Amina Audu, a student nurse, was the first to administer first aid to Dawn, the inquest heard.

She was nearing the end of a 12-week placement at Goodmayes Hospital as part of her studies. While she was in the office doing progress notes, a member of staff starting banging on the window asking for help.

"I could see the distress on his face so I knew something was wrong," Ms Audu said.

When she got to the dining room, Ms Audu started performing back slaps and the emergency procedures required for choking.

The inquest heard that Ms Audu was assisted by a support worker, but senior nurses did not take over.

Both Dawn's family and Ms Persaud said she had done an "excellent job" considering her experience.

Nicole Sewell was the nurse lead for the ward at the time of the incident and Ms Persaud asked why senior staff did not take "leadership of the situation".

"I didn't want to leave Dawn. I was with them every step of the way - I didn't want to take a step back," Ms Sewell said.

Ms Sewell said the priority was to dislodge the food, rather than use emergency equipment, such as a defibrillator or oxygen.

She told the family: "Not a day goes past when I don't deeply regret the incident. I can assure you that staff are working very hard to ensure this doesn't happen again."