A 96-year-old pensioner tragically died after care home staff failed to alert paramedics she had eaten dinner shortly before her collapse, an inquest has heard.
Ivy Dixon, a resident at Acorn Lodge Care Home in Hackney, passed away on the evening of 6 October 2023 after her airway became blocked.
Staff on duty that night told London Ambulance Service crews that she had not been fed, leading them to mistakenly apply a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.
The DNACPR directive, however, only applied to non-reversible medical events, not to incidents like choking.
False Information Provided to Paramedics
At the Inner North London Coroners’ Court, Assistant Coroner Ian Potter expressed serious concerns over the misinformation provided.
He noted that although it was unclear whether the correct information would have altered the outcome, the miscommunication was grave enough to warrant a formal prevention of future deaths report to Lukka Care Homes Limited.
In his letter, Mr Potter referenced a healthcare assistant’s evidence. She confirmed that Ms Dixon had indeed been fed and that she heard “a noise” from the elderly woman’s chest, prompting her to call for help.
Nursing staff responded, quickly suspecting that Ms Dixon was choking. They noticed her oxygen levels had dropped significantly and contacted emergency services. During the 999 call, it was mentioned that Ms Dixon was choking but remained conscious.
Yet when paramedics arrived, they were incorrectly informed that Ms Dixon had not eaten — only that she had gasped during an attempt to feed her.
Mr Potter remarked: “This raises concerns about the communication and integrity of the staff members at the Care Home in their provision of care to the patient. I did not receive any reassurance that this concern has been addressed.”
Missed Opportunity for Lifesaving CPR
Shockingly, despite Ms Dixon losing consciousness, ceasing breathing, and losing her pulse within six minutes, no CPR was attempted by staff before the ambulance crew arrived.
Mr Potter was clear in his findings: the DNACPR order should not have applied in this case, as choking is considered a reversible cause of cardiac arrest. The care home manager confirmed this during her testimony.
The coroner added: “This raises the concern that staff (healthcare assistants and nursing staff) at the Care Home may have previously unidentified training needs and/or lacked the clinical skills/knowledge to provide emergency care.”
Lukka Care Homes Limited has been contacted for comment but has yet to respond.
This heartbreaking case highlights critical failings in emergency training and communication within care homes. Ivy Dixon’s death, while possibly unavoidable, has prompted fresh calls for immediate improvements to how care homes manage urgent health crises, particularly where DNACPR orders are concerned.
Authorities are now awaiting a response from Lukka Care Homes Limited, as the focus shifts to preventing a repeat of such a devastating incident.
