Disabled woman choked to death while eating cake

A disabled woman died when she choked after eating cake, despite therapists advising she should only eat pureed food, an inquest has concluded.

Emma Turner, 30, died at her home in Derby in January 2023 when her airways became blocked by vomit after she ate cake.

A prevention of future deaths report issued by the area's assistant coroner Sabyta Kaushal said evidence at the inquest "exposed important issues with information sharing between services".

Derby City Council and Derbyshire County Council have both been sent the report and have until 23 April to respond to the coroner's letter.

In the report, published at the end of February, Kaushal said Turner had been "profoundly disabled" with quadriplegic athetoid cerebral palsy since birth.

When discussing her care, the coroner said agencies did not discuss her needs regularly, nor were safeguarding referrals fully addressed.

She said speech and language therapists did not see the patient in person for 11 years between her transition from child to adult services.

When she was assessed, therapists advised she should only eat pureed food, the report said.

However, there was no face-to-face assessment regarding her clinical needs, her social needs nor adequate welfare checks from 2019 until her death.

Kaushal said in the report that Turner's mother, who was her carer, should have been given "more support and assistance in understanding what was in Emma's best interests".

The coroner said there had been a history of non-attendance and reluctance on the part of family members to engage with services.

As a result, safeguarding referrals were made by a day centre in 2018 and by a social worker after discussions with an advanced nurse practitioner at her GP surgery a year later.

However, information sharing practises meant agencies were less able to see how each other could have helped the patient.

Speaking at the inquest, her GP surgery, Derby City Council and its safeguarding team confirmed a number of "relevant changes" were being made to they way they look after patients with learning difficulties, particularly those who had not attended a number of appointments, the report said.

However, Kaushal concluded the contents of the current safeguarding referral form, which needs to be completed by a GP for vulnerable adults with learning difficulties, was not tailored to the type of concerns a GP would raise.

This means safeguarding teams might have a lack of key information, creating the potential for delays in responding in a timely way, she added.

Alison Martin, Derby City Council's cabinet member for health and adult care, said the authority was taking the report findings "seriously".

"Since Emma's death, work has already been undertaken with partners to review the circumstances and strengthen information sharing and safeguarding processes for vulnerable adults, including those with learning disabilities," she said.

"We are carefully considering the coroner's report and will provide a full response within the required timeframe, setting out any further actions to ensure the learning is fully embedded."

A spokesperson for Derbyshire County Council said: "We'd like to express our deepest sympathies to everyone who knew and loved Emma.

"We'll work with partners to address concerns raised by the coroner and improve joint processes for sharing information between agencies."

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