It happened while Ronald James Jepson was residing at Meadow House in Radford

A Coventry OAP was found to have died following an incident in which he ‘choked on jam sandwiches’. It happened while he was residing at Meadow House on Links Road in Radford.

Area Coroner Delroy Henry carried out an inquest into the death of Ronald James Jepson at Coventry Coroners Court. His death was ruled as misadventure, whereby the deceased is understood to have voluntarily undertaken some sort of risk that led to their untimely end.

Mr Henry said Mr Jepson had a history of schizophrenia and resided at city-based mental health unit Meadow House. His care plan stated that he was supposed to be supervised when provided with a meal or eating.

Mr Jepson had a known risk of cramming food into his mouth and thereby choking. On March 14, 2023, the 75-year-old was sat in the TV lounge and provided his supper which consisted of some jam sandwiches, Mr Henry said.

It was inconclusive whether the jam sandwiches were cut into sufficiently small pieces, a Prevention of Future Deaths Report stated. Mr Jepson, his plate cleared from the room, had an unwitnessed choking episode a short time later, Mr Henry said.

Staff at Meadow House rushed to the TV lounge upon hearing Mr Jepson ‘gargling’ and dialled 111. Mr Henry said attempts at resuscitation were following a considerable period of time, due to them being ‘inexperienced and panicking.’

Paramedics attended but Mr Jepson had ‘turned blue’ by the time they had arrived, Mr Henry said. Crews attempted to resuscitate 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 food he was given at Meadow House. Mr Henry said the jam sandwiches had got ‘lodged in his windpipe which prevented air from getting to his lungs thereby damaging vital organs and causing his heart to stop.’

Mr Henry said during the inquest that the evidence revealed that ‘there is a risk that future deaths will occur unless action is taken.’ He said timely interventions from staff can have a significant bearing on the outcome of someone choking.

Staff were also said to have dialled 111 instead of 999 despite the fact that Mr Jepson was becoming unresponsive and heard ‘gargling.’ A call handler recognised it was an emergency and escalated matters, Mr Henry said.

Training at the time of the incident was described by Mr Henry as ‘ineffectual and infrequent.’ It meant that when an emergency arose the actions of staff to aid a resident were ‘sub-optimal.’

Meadow House has been approached for comment by CoventryLive