Hospital apologises to family after man choked on large piece of meat

A DUBLIN hospital has issued a formal apology to the family of a patient who choked on a large piece of meat when he was meant to be on a supervised soft and bite-sized diet because of his known swallowing difficulties, By Seán McCárthaigh.

A verdict of death due to misadventure was recorded at an inquest on Tuesday into the death of Derek Adamson (66), a widowed father of three from Killinarden Heights, Tallaght, Dublin 24, at Tallaght University Hospital on May 2, 2024.

A sitting of Dublin District Coroner’s Court heard the retired taxi driver had been admitted to the hospital’s acute psychiatric unit following a manic episode seven months earlier.

He spent the last two weeks in an intensive care unit following a choking incident on April 19, 2024.

A consultant psychiatrist at TUH, Thomas McMonagle, gave evidence that Mr Adamson had a very complex medical history including a codeine dependency, diabetes, delirium and seizures.

Dr McMonagle said the deceased was admitted involuntarily in October 2023 and was extremely unhappy about being in hospital and had made a number of attempts to leave.

However, the inquest heard he gained enough insight to become a voluntary patient by December 2023 after which he was allowed to go home to stay with his daughters at weekends.

Dr McMonagle said there were concerns about the patient’s cognitive decline even before the manic episode and he was assessed as having multiple risk factors including falls and choking so that long-term care in a nursing home became the most viable option.

The inquest heard that Ms Adamson’s daughter had told doctors at a meeting in November 2023 about choking incidents at home and nursing and catering staff at TUH were advised that he needed supervision at mealtimes with a recommendation that he be given soft, bite-size food.

A speech and language therapist, Stephanie O’Connor, said the patient’s meal plan would have been available on a notice board and in his charts.

It stated Mr Adamson was to have a diet of soft and bite-sized food, take a sip of liquid between mouthfuls and to be supervised at mealtimes.

Ms O’Connor said it was the job of hospital staff to check such information.

Catering staff provided statements which said Mr Adamson had come into the dining room on April 19, 2024 and queued for food, ordering two slices of beef, potatoes, vegetables and gravy.

Folake Omotayo gave evidence that there was no modified meal plan for the patient on the notice board for catering staff.

However, she did acknowledge seeing nursing staff supervising him eating his meals.

A psychiatric nurse, Ogonna Idemili, who was supervising a number of patients including Mr Adamson in the dining room, said he suddenly stood up while having his lunch at around 1.05pm and grabbed a jug of milk from a trolley.

Ms Idemili, who was aware that the patient was at risk of choking, said she immediately went over to him and saw he had difficulty responding.

She said another nurse attempted to perform the Heimlich manoeuvre but the patient fell to the floor, after which CPR was commenced.

An assistant director of nursing, Keith Barter, told the inquest that he removed a piece of brown meat approximately 3-4cms in diameter from the back of Mr Adamson’s airway with a forceps but there was no response from the patient.

In reply to questions from counsel for Mr Adamson’s family, Doireann O’Mahony BL, Mr Barter said the piece of meat was “definitely larger than bite-sized.”

The inquest heard that the patient was subsequently transferred to the hospital’s ICU where he died two weeks later without regaining consciousness.

A postmortem showed Mr Adamson died from injuries caused by a lack of oxygen to the brain due to a choking incident when a piece of meat obstructed his airway.

One of the deceased’s daughters, Linda Adamson O’Donnell, said her father was on a specific meal plan and was supposed to have one-to-one supervision.

Ms Adamson O’Donnell said it was clearly stated in his plan that no piece of meat or other food should be bigger than 1-1.5cm so that he would not need a knife to cut food.

She told the inquest that her family were outraged and appalled over why the meal plan had not been followed.

The witness also criticised TUH over the failure to notify them while visiting the hospital that their father had suffered a large seizure on April 25, 2024.

Asked by coroner Clare Keane about any changes at TUH as a result of the circumstances of Mr Adamson’s death, Dr McMonagle said it had become very clear during a serious incident review that ensuring personal meal plans were delivered appropriately to patients was

“incredibly complex” and that some overarching coordination was needed.

Dr McMonagle said a new standard operating procedure had been introduced in the hospital within six weeks of the choking incident with specified roles for all staff about the transmission of information and supervision.

He told the inquest that a separate system analysis by an independent group had made 22 recommendations, of which 19 had already been implemented.

The psychiatrist said the main outstanding recommendation was to address a finding that there was an insufficient number of speech and language therapists at TUH.

However, Dr McMonagle said no extra specialists had been provided, despite the hospital making a business case for more speech and language therapists.

Ms O’Mahony said Mr Adamson’s family were heartened and greatly comforted by the changes.

She urged the jury to record a verdict of death due to misadventure.

Ms O’Mahony said Mr Adamson had been looking forward to moving to a nursing home near his family including his nine grandchildren who were “the centre of his world.”

She said his absence had “left a void which can never be filled.”

Counsel for TUH, Brian Sugrue BL, called for a verdict of accidental death on the basis that there was no intention to give a meal to the patient that did not comply with his meal plan.

A jury of six women and one man recorded a verdict of misadventure and also recommended that the level of speech and language services be increased in TUH as well as the level of supervision in the hospital’s dining area.

Offering her condolences to Mr Adamson’s family, coroner Clare Keane, acknowledged that there had been some conflicting evidence which the inquest had not been able to resolve.

However, Dr Keane expressed hope that some of their questions had been answered, while she said she would also draw the jury’s recommendation to the hospital’s management.

Following the verdict, Mr Sugrue issued a formal apology to Mr Adamson’s family on behalf of TUH and expressed deep regret for the circumstances which led to his  “untimely and tragic death.”