Inquest hears that patient choked on piece of meat

An inquest into the death of a patient in University Hospital Galway who apparently choked on a piece of red meat has been adjourned to establish how the elderly man on a moist mince diet could have been served the wrong meal.

Galway West Coroner, Dr Ciarán MacLoughlin adjourned the hearing until next year so that a former catering employee on duty that day could be located to give evidence.

The Coroner’s Court last week heard three hours of evidence into the death of Patrick Monaghan (85) of St Jarlath’s Court, Tuam, who was found dead in a chair beside his hospital bed on October 4 last year shortly after eating his lunch.

His lunch tray was still on his bed trolley and staff noticed it was a beef dinner though a sign over his bed stated he was only to be fed ‘moist mince meals’ which would not have any chunks of food in them for easy digestion.

However, it transpired that the late Mr Monaghan may have inadvertently been given the wrong tray carrying the wrong type meal on the day.

Mr Monaghan had been in hospital for four months at the time and had been waiting to be discharged once a bed was available in a nursing home. He had had difficulty swallowing food which is why he was on a modified diet.

Consultant Pathologist, Dr Sheena Phelan, told the Inquest that the cause of death had been asphyxia due to a piece of food obstructing his larynx. She had found pieces of red meat and carrots measuring about three to four centimetres.

Annemarie Burke, Clinical Nurse Manager on St Dominick’s Ward, remembered that the patient had been given a regular dinner on September 24 and when he couldn’t digest it, the catering staff had been reminded of his modified diet.

On cross-examination by Paul McGettigan, SC for Mr Monaghan’s family, and Ian Thomas, representing Aramark Catering Company which provides meals to patients, she said she had written up the incident on the day but couldn’t remember if she followed up with a phone call.

In the course of her evidence, she remembered seeing Mr Monaghan slumped on a chair beside his bed and that his tray was still on his bed trolley. Later she remembered noting it had contained the remnants of a regular beef meal.

However, at the time she didn’t make the connection as she hadn’t known or expected him to have died from choking.

Gavin O’Shea, Campus General Manager with Aramark at UHG, told the Inquest that the company had since 1984 provided 766,000 patient meals per annum at GUH, serving 1,200 patients daily across the group which included both UHG and Merlin Park in Galway as well as Mayo General Hospital. In that time, he said, this was the first time a patient had choked on a meal at the hospital.

At UHG, the food is cooked by professional chefs in the main kitchen and served from pantry kitchens on each floor across four separate buildings on the campus. Two members of staff served the food on each ward per meal service which included, breakfast, lunch and supper.

Most patients were served regular meals while some were on modified diets such as an easy chew or liquified. These modified meals were served on red trays which also indicated if a patient needed assistance while feeding.

The red tray list was compiled by the clinical staff each day and cross checked the following day by the serving staff who made changes on a white board to ensure each patient got the right meal, which were identified by bed numbers.

The modified meals were clearly distinguishable from others in marked containers. These were delivered to the beds but away from patients to be assessed by clinical staff, not Aramark staff, he said. Staff were fully trained by Aramark on the serving of these blue and red trays.

Mr O’Shea said that his own investigation of the incident showed that his staff received a photocopy list of the previous day’s meals requirements for October 4 and according to that list, Mr Monaghan should have got a normal meal. That didn’t happen, he added, because of information on traceability sheets which showed the serving staff that he should be given a modified meal, which was the correct meal for him on the day.

“He received a mince moist meal instead of a normal meal on that day because we knew he was a long-term patient and that the catering staff went down the ward to confirm verbally what he did receive. If we had followed instruction that morning, he would have been delivered a normal meal,” he added.

The Coroner, Dr McLoughlin asked how he could marry that evidence with that of the previous witness, Ms Burke, who said she saw evidence of a normal meal on the patient’s tray that day.

Mr O’Shea said he couldn’t explain how a piece of meat was in his oesophagus that day but added if Mr Monaghan had been given the wrong meal, another patient would have complained of getting a mince moist meal. Mr Monaghan was the only patient of 28 on the ward on a mince moist meal that day.

The mince moist meal on the day was turkey mince with pureed vegetables and mashed potatoes. The normal meal was a beef stew. He said that there had been nothing unusual about the food service on the ward that day.

“If there had been some mix-up, this would have been brought to our attention,” he said. It was a tried and trusted method and only clinical staff assisted patients to eat, not the serving staff.

Since the death of Mr Monaghan, they had taken steps by providing further training to staff, and he offered his condolences to the patient’s family.

Mr O’Shea said he had been informed six days later that a patient had choked to death. Replying to the Coroner, he said there was no investigation following an alleged incident of a wrong meal delivered over a week previously because he had never received an incident report or been informed by phone or email.

Dr McLoughlin said that it appeared that the wrong meal had been in front of the patient and that it was now associated with how he died. He said he appreciated it was laborious to write lists but he was concerned about such lists being photo-copied.

In reply to Mr McGettigan, representing the Monaghan family, he asked why the catering assistant who served meals on the ward that day wasn’t available to give evidence.

Mr O’Shea explained that the person, whom he called Michael (he couldn’t remember his surname) was no longer a staff member.

Legal representatives for the HSE agreed that this witness be made available to the Inquest.

Mr McGettigan said that nobody had complained about receiving a wrong meal – but Mr Monaghan had been served a wrong meal because he was served one with chunks of beef in it.

Mr O’Shea said he had just been made aware 48 hours before the Inquest of a beef dinner being in front of Mr Monaghan when he was found slumped in his chair.

He said he accepted that hypothetically it could happen but he still stood over his own statement that a modified meal had been prepared and delivered that day to the patient.

But Mr McGettigan said that the person who served the meal to Mr Monaghan hadn’t confirmed directly to the Inquest if that had been the case. He said that Michael’s presence was required so he could give that evidence.

The Coroner agreed and it was decided to adjourn the Inquest until the March sitting of the Coroner’s Court. He further asked all parties concerned to produce all documents in relation to the case before that date as there was conflicting evidence on what meal had been delivered to Mr Monaghan that day, as well as other issues that had to be teased out.