Bonita Cleary

I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde

INVESTIGATION and INQUES The death of Bonita Cleary on 11 th October 2025 at Delaheys Nursing Care Home, Lytham St. Annes was reported to me and I opened an investigation which  concluded by way of an inquest on 8th January 2026. I determined that the medical cause of death was: 1a Choking II Severe frailty, left ventricular hypertrophy, coronary heart disease, dementia. In box 3 of the Record of Inquest I recorded as follows: Bonita Cleary was aged 75 years. Her medical history included dementia and she  was known to be severely frail. She was not regarded as being at risk of choking,  but sufficiently frail that when eating, her food needed to be easy to chew and a  member of staff present. On 11 th October 2025, at a time when a Care Assistant had commenced feeding her small portions of crumpet for lunch, Bonita started  coughing and had what has been described as a vacant episode. Her jaw became  clenched. She began choking and the food caused an obstruction of her airway.  She had a DNACPR [Do Not Attempt Cardio – Pulmonary Resuscitation]  authorisation in place. CPR was not initially commenced with a view to trying to  reverse the effects of choking until a Paramedic attended who was able to remove food from Bonita’s airway but by that stage from the available evidence she could  not be revived. A subsequent post – mortem examination confirmed she died from the effects of choking, her death more than minimally contributed to by her  known severe frailty, compromised heart function, and dementia. In box 4 of the Record of Inquest I determined that: Misadventure

In addition to the contents of section 3 above, the following is of note: ·   Bonita Cleary was largely bedbound during her final weeks; ·   She was not regarded as at significant risk of choking, and she was not  restricted in terms of the range of foods she could eat, but there was a need to for a member of staff to be with her when she ate; ·   With a member of staff in attendance, she began eating some pieces of crumpet which had been cut up for her; ·   She did have a history of what were described as seizures / vacant episodes of varying duration, and on such occasions her jaw could become clenched and lock; ·   This happened unexpectedly after she began eating the crumpet, and she  appeared to be choking. A member of care staff, and then a nurse, both of whom were familiar with Bonita and had cared for her for many months,  tried to assist her by making attempts to clear any food from her mouth; ·   When a paramedic attended, CPR was not being performed; ·   The Paramedic made efforts to remove more food from the airway, and commenced CPR, but in due course it was confirmed Bonita had died; ·   There was a DNACPR (Do Not Attempt Cardio-pulmonary resuscitation) authorisation in place; ·   It seems there was a lack of awareness that even if there is a DNACPR in  place, CPR can be commenced to respond to potentially reversible causes. Choking is one such reversible cause; ·   The Nurse gave helpful evidence at the inquest, whilst acknowledging that despite her years of experience, and had previously received basic life  support training, she was not fully aware that CPR may still be required in  the event of a potentially reversible cause and she firmly expressed the  view there is a lack of guidance on this issues for medical professionals and care workers employed in a care setting. A senior manager in attendance at the inquest agreed. ·   I considered if, had effective CPR been commenced immediately, this  would have made a difference to the outcome for Bonita? Although I could not rule this out, I regarded it as unlikely. Having considered all of the above, I have determined that I have a duty to write this report.

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 send the report: The MATTER OF CONCERN is as follows. – ·   Bonita Cleary died due to a choking episode. ·   This is a potentially reversible cause. ·   Notwithstanding there was a DNACPR authorization in place, CPR ought to have been commenced ·   On balance of probabilities, this would not have saved Bonita’s life, but for other vulnerable residents in a care setting, effective and timely CPR may  prevent death; ·   I am concerned that there is a lack of awareness amongst care and nursing staff within this organization and the care sector more widely about when  CPR should be attempted, and that residents with a realistic chance of  surviving may die as a result of a cause which was, in fact, potentially  reversible. ·   It is not for me to be prescriptive about what can / should be done, but there is a clear risk and therefore I raise this concern.

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