Margaret Taylor

I am Rebecca Ollivere, Assistant Coroner for the coroner area of Gloucestershire

On 25 th November 2024, an investigation was commenced into the death of Margaret Taylor. The investigation concluded at the end of the inquest on 12 th August 2025. The conclusion of the inquest was as set out below.

Margaret (Maggie) Taylor was 80 years old and resided at Oak Tree Mews Care Home in Gloucestershire. She suffered with Dementia, and Dysphagia, and a Speech and Language Therapy (SALT) review, had identified her as a severe risk of choking. She was last assessed on 9 th September 2024, and placed on a level 5 soft food diet and thickened fluids. Food was to be soft and mashed. No review of her SALT assessment was carried out in October 2024, however, she was taken off the level 5 diet and this communicated via a Whatsapp message to all staff at the care home. There does not appear to be any rationale for this decision, and it does not seem to be a decision taken following a proper assessment. On 8 th November 2024, Maggie’s husband took into the care home, a chicken wrap, which he fed to Maggie. The evidence I heard was that he believed that Maggie had been removed from the soft food diet. He also indicated that the food was not checked for suitability by the staff at the home. I heard that this is against the policy of the home, which indicates that all food should be checked by staff. Sadly, Maggie began choking on a piece of chicken, and despite the best efforts of all involved, and paramedics who attended, she could not be resuscitated, and died at 12.40pm on 8 th November 2024. The conclusion of the Inquest was that Margaret died as the result of an Accident. It is not known whether had the staff checked the food brought in by Mr Taylor, it would have been highlighted as not suitable, as she had been taken off the soft food diet, and so it may well be that it would still have been allowed. Therefore, I cannot say that there would have been any difference to the outcome for Maggie in this case had the staff checked the food.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.  – – There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet – Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.