Woman died from brain injury after choking on sandwich at mental health hospital, inquest hears

A 54-year-old woman died from a brain injury caused by choking on a sandwich, an inquest jury heard yesterday.

The first day of the inquest at Winchester Coroner’s Court heard that Tracy Ann Young, from Liphook, was a patient at Parklands Hospital in Basingstoke when the incident occurred on February 18 last year.

Ms Young, whose family is from the Farnham area, was receiving mental health care at Parklands and had been placed in a room used to help patients de-escalate.

The jury was shown an hour of closed-circuit television footage from the room leading up to and including the incident and its aftermath, when staff went to Ms Young’s aid.

It was difficult to establish exactly what had happened because the footage was recorded by a black-and-white ceiling-mounted camera without sound. Ms Young also collapsed through an open doorway, out of sight of the camera.

Ms Young was rushed to the intensive care unit at Basingstoke and North Hampshire Hospital, where she remained until March 26.

When it became clear that her condition was not going to improve, she was transferred to St Michael’s Hospice in Basingstoke for end-of-life care.

She died there on March 30 with her mother by her side. The cause of death was recorded as a hypoxic brain injury and choking on food.

Basingstoke and North Hampshire Hospital pathologist Dr Hayder Alkhazaraji carried out a post-mortem examination on April 3.

Although Ms Young had suffered a cardiac arrest during the incident, he did not find any problems with her heart or coronary arteries, and her eating and swallowing system appeared normal.

He added: “I can’t tell you how long the brain would need to be starved of oxygen before causing a serious enough injury to cause death.”

Healthcare support worker Morgan Riley was one of two staff on observation duty at the de-escalation room, known as the 136 Suite, when the incident occurred.

Miss Riley described the 136 Suite as “a place of safety”.

Before being taken there, she said, Ms Young was “very manic, chaotic, elated”.

She added: “She was aggressive, attempting to punch staff and throwing objects around the room.”

Miss Riley said observations took place through a large window, with the two staff on duty taking turns to work hour-long shifts and recording the patient’s condition every 15 minutes.

She added: “Observation is seeing if the risks are escalating, and one of the two staff should have their eyes on the patient at all times. You’re not allowed to have your mobile phone or anything that will distract you.”

Miss Riley noticed a stale-looking tuna sandwich just behind the mattress in the room.

She said: “As she was manic, chaotic and fast-moving, I didn’t want her eating at the time.”

One of the two staff on duty had removed the sandwich, she said, although she could not remember whether it was her or her colleague.

She added: “I remember the sandwich, definitely, and it was removed because of her presentation. She didn’t appear a choking risk and had no swallowing difficulties. It was just her presentation.

“But it wasn’t the one Tracy choked on, and it was removed.”

The inquest into Ms Young’s death is due to last nine days.