Coventry man dies after ‘blowing on jam sandwiches’

A Coventry PLO has died following an incident where he “choked on jam sandwiches”. It happened while he was living at Meadow House on Links Road in Radford.

Area Coroner Delroy Henry held an inquest into the death of Ronald James Jepson at Coventry Coroners Court. His death was considered an accident, meaning that the deceased voluntarily took some kind of risk that resulted in an untimely end.

Mr Henry said Mr Jepson had a history of schizophrenia and lived at the city’s mental health facility Meadow House. His care plan stated that he should be supervised when he is given a meal or eats.

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Mr Jepson had a known risk of stuffing food into his mouth and therefore choking. On March 14, 2023, the 75-year-old sat in the TV lounge and offered himself dinner, which consisted of jam sandwiches, Mr Henry said.

It was inconclusive whether the jam sandwiches were cut into small enough pieces, a report into preventing future deaths found. Mr. Jepson, with the plate released from the chamber, had an unassisted choking episode a short time later, Mr. Henry said.

Staff at Meadow House rushed to the TV room after hearing Mr Jepson “gargling” and called 111. Mr Henry said resuscitation attempts took a considerable time as they were “inexperienced and panicked”.

Paramedics attended but Mr Jepson had “turned blue” by the time they arrived, Mr Henry said. Crews attempted to revive the 75-year-old at Meadow House and University Hospital Coventry, but he was pronounced dead on March 15, 2023.

Mr Jepson suffered a cardiac arrest which was precipitated by the episode of choking on the food he was given at Meadow House. Mr Henry said the jam sandwiches were “stuck in his trachea, which prevented air from reaching his lungs, thus damaging his vital organs and causing his heart to stop”.

Mr Henry told the inquest that the evidence showed “there is a risk that further deaths will occur if action is not taken”. He said timely interventions by staff can have a significant influence on the outcome of someone’s choking.

Staff were also said to have dialed 111 instead of 999 despite Mr Jepson being unresponsive and hearing “gargling”. A call operator recognized it was an emergency and escalated the issues, Mr Henry said.

The training at the time of the incident was described by Mr Henry as “ineffective and sparse”. It meant that when an emergency arose, staff actions to help a resident were “suboptimal”.

Meadow House has been contacted for comment by CoventryLive.

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