A coroner has expressed concerns after the death of an 85-year-old woman who choked on her prescription medicine.

Sally Mills, who lived in Berkshire, died in Slough on July 23 last year after choking on a tablet administered by a care assistant.

An inquest investigation was opened at Reading Coroner’s Court on July 28 last year and concluded on October 22.

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The conclusion was Ms Mills died as a result of choking on her prescribed medication, which was contributed to by continued administration of medication following signs of difficulties in swallowing against a background of recent difficulties.

A forensic post- mortem examination concluded her medical cause of death was consistent with choking.

However, coroner Priya Malhotra expressed concerns following Ms Mills death surrounded a lack of first aid training and escalation of issues encountered by health care assistants.

During the inquest, it was heard that Ms Mills received carers four times a day at her home address and they assisted her in the administration of her medicine. She took five tablets in the morning.

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Following concerns, raised by the district nurse on July 18 last year, regarding swallowing of tablets, care  assistants  were  advised  to  keep  Ms Mills at  a  90-degree  angle  when administering medication.

This was implemented into her care plan.

Several days later, on July 22, further difficulties with taking the medication were noted twice that  day and not escalated.

The following day, Ms Mill’s medication was administered with the assistance of a care assistant at home.

She was displaying signs of discomfort following the third tablet and then difficulty swallowing the fourth tablet.

Ms Mills then choked after taking the fifth tablet and became unresponsive. Paramedics attended and she was rushed to Wexham Park Hospital in Slough where she passed away the same day at 9.30am.

Coroner Ms Malhotra was concerned that the evidence revealed there is still a lack of understanding of providing first aid to those becoming unresponsive.

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She was also concerned that the evidence demonstrated efforts have been made in this regard, such as a new checklist, and new policy dated September 2023; the evidence revealed lack of knowledge of the policy and embedding of it.

Ms Malhotra wrote a ‘prevention of future death report’ with her concerns and sent the letter to Caremark (Chilterns and Three Rivers), a home care service in Chesham.

The business has 56 days to reply to the coroner with details of actions taken or proposed following the concerns expressed or else explain why no action has been proposed.