Death of man who choked on meat at Dublin hospital ‘tragic and traumatic’, inquest hears

The inquest of a man who died after he choked on a piece of meat at a Dublin hospital while he was supposed to be on a soft food diet has heard that his death occurred in “tragic and traumatic circumstances”.

Derek Adamson (66) of Killinarden Heights, Tallaght, died at Tallaght University Hospital on May 2nd, 2024, following the choking incident on April 19th.

Dublin District Coroner’s Court heard on Tuesday that his cause of death was hypoxic-ischaemic encephalopathy, a brain injury caused by a reduction in oxygen and blood flow, secondary to a choking episode via obstruction to the airways by a piece of meat.

A verdict of misadventure was returned by the seven-person jury at the court on Store Street. Tallaght hospital issued a formal apology following the inquest, and said it “deeply regretted the circumstances” which led to the “untimely and tragic death” of Adamson.

A retired taxi-man and father of three, Adamson was an inpatient at the hospital due to a history of manic episodes, seizures and problems with cognitive function.

Stephanie O’Connor, a specialist speech and language therapist for the HSE, told the inquest that Adamson had previously experienced a number of choking incidents at home and had swallowing difficulties.

Adamson’s swallow was “much less effective” than a normal person’s, and he was therefore on a level six hospital diet which consisted of soft and bite-sized food, she said.

O’Connor said his meal plan was on a notice board in the hospital and in his charts and it was staff’s responsibility to “look at that [board] every day”.

O’Connor also said it was recommended there should be supervision at his mealtimes, and that Adamson should take a sip of water after every mouthful of food.

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Catering staff at the hospital said there was no modified meal plan on their notice board for Adamson on the day in question and that he had queued for food at lunchtime, collecting two slices of beef, potatoes, vegetables and gravy.

Staff then noticed Adamson got up from the dining table, went to a nearby milk trolley and was trying to drink milk, which was spilling over him.

The alarm was raised and the Heimlich manoeuvre was attempted, but Adamson fell to the ground and CPR was commenced.

Keith Barter, an assistant director of nursing at the hospital, said he removed a piece of meat approximately three to four centimetres in diameter from the back of Adamson’s throat.

Adamson was transferred to ICU, where he died two weeks later after failing to regain consciousness.

Dr Thomas McMonagle, consultant psychiatrist and clinical director at the hospital, said an external systems analysis was subsequently conducted, which resulted in 22 recommendations, three of which were outstanding.

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McMonagle said the review found insufficient speech and language provision in the hospital and a business case for this had been escalated, but so far there had been no uplift in resources.

In its verdict, the jury recommended the level of speech and language therapy increase at the hospital, as well as the level of supervision in dining areas.

McMonagle also said Adamson was looking forward to discharge to a chosen nursing home near his family when the incident occurred and offered his condolences to the family “for their loss and the tragic and traumatic circumstances in which it occurred”.

Adamson’s daughter Linda said the circumstances surrounding her father’s final days had left her and her sisters Elaine and Amanda with “memories that are incredibly difficult to live with”.

“The uncertainty, the distress, the things we witnessed and the things we struggled to understand have had a lasting emotional impact on all three of us,” she said.

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“We were faced with a situation that none of us could ever have prepared for. We had to process the reality that our Dad was critically ill and that ultimately we were going to lose him.”

She said her father “loved his family” and that they would miss his “sense of humour, his jokes and that infectious way he could make us laugh”.