Independent investigation after woman was choked to death in disabled care home – The Irish Times

An independent investigation is underway into the death of a resident of a disability accommodation center 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 lived for 12 years in a residential center run by disability service provider Sunbeam House Services.

An inquest into her death this week revealed the woman died after choking on a piece of toast as center staff and paramedics tried unsuccessfully to save her life.

Sunbeam House Services operates a number of residential centers for adults with developmental disabilities, as well as respite and day services. Ms Evans resided at her Rosanna Gardens center in Ashford, Co Wicklow.

An inquest at the Bray courthouse earlier this week heard she died on the morning of October 25, 2021.

Two social workers at the daytime center gave evidence to the inquest, who heard that Ms Evans had been in bed that morning and had asked for a piece of toast to eat. The resident then walked into the residential center staff office, they told the inquest.

One of the social workers described Ms Evans as looking ‘a bit discoloured’ and said she appeared to be struggling to ‘catch her breath’. She then began to gasp, before collapsing to the floor, staff said.

The two carers in the office put Ms Evans in a recovery position and called the emergency services. Staff then began CPR compressions on her until paramedics arrived. Paramedics were unable to resuscitate her and she was later pronounced dead.

An autopsy of the body revealed the “presence of small pieces of chewed bread present in the trachea”.

At the inquest, the coroner asked staff at Sunbeam House if any efforts were made to remove the toast from the resident’s throat after she collapsed. One of the staff said he did not try to remove the food, but the paramedic tried to when he arrived.

The inquest also heard that Ms Evans suffered from Parkinsonism as a result of medications she was taking, which allegedly slowed her down.

Joe Lynch, chief executive of Sunbeam House, said the organization expressed “our deepest condolences to the family involved in the wake of this tragic accident last year”.

The disability service provider reviewed all incidents in accordance with Health Services Directorate policies, he told the Irish Times.

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

Gordon Jeyes, the former chief executive of Tusla, the agency for children and families, is leading the investigation. Its report should be completed before the end of the year.

Mr Jeyes previously led an internal investigation for the organization in 2018, into allegations of poor practice at one of its centers in Arklow, which found there was an ‘institutional’ approach to care at the facility .