A 30-year-old Sheffield woman with cerebral palsy died after a support worker at a day care centre fed her yoghurt while she was sat in a 'relaxation' chair a medic warned should not have been used for feeding, an inquest heard.
Sheffield Coroners' Court was told how Cheryl Crawford, who was not able to communicate verbally, passed away at the Cambian Specialist Day Service Centre in Spa Lane, Woodhouse on at 10.55am February 28 this year.
Giving evidence at Cheryl's inquest at the Sheffield Medico Legal Centre yesterday, Dr Panagiota Kitsanta, recorded her primary cause of death as being aspirational pneumonia, which is defined as a chest infection that can develop after accidentally inhaling something, such as a small piece of food. She also confirmed that bits of yoghurt were found in Cheryl's larynx during her autopsy.
Records from Ms Crawford's GP confirmed she had a variety of complex medical conditions including cerebral palsy, epilepsy, severe learning difficulties as well as problems with swallowing. The court was told that Ms Crawford was hospitalised twice in February this year with aspirational pneumonia.
Cheryl, who was wheelchair-bound, was being fed in a borrowed 'p-pod' chair, at the CSDSC when she fell fatally ill. P-pod chairs are bean bags with postural support that are commonly used to provide people who use wheelchairs with relief from their chairs.
CSCSC Support Worker, Teresa Kelk, was feeding 'bubbly' Cheryl when she fell ill, and told the court she had fed Cheryl her mid-morning yoghurt snack while she was sat up-right in the p-pod chair 'many, many times' without any problems.
She told the court that she reviewed Cheryl's care plan daily, and had never seen it written, or had it communicated to her by any other method, that Cheryl should not be fed in the p-pod chair.
"She took the first mouthful fine. Cheryl's one of those who will close their mouth until she knows she's ready for the next one. I gave her the next one and the third," Theresa told the court.
She added: "I was giving her the fourth and she went pale in colour. I shouted my colleague across to me because I knew something was wrong."
Ms Kelk said that they soon realised Cheryl was not breathing, and CPR was commenced as other members of staff at the centre contacted the emergency services.
The Yorkshire Ambulance Service received the call at 9.55am, and arrived on the scene shortly afterwards. Despite the best efforts of medics, Cheryl sadly passed away at the centre at 10.55am that morning.
Susan Crawford, Cheryl's mother, told the court that when Cheryl was measured for a p-pod chair to be used at home, Cheryl's physiotherapist, Christopher Smallshaw, told her that Cheryl must 'never be fed' in the chair, and suggested it was for 'relaxation' only.
She said: "We were told you must never give her food or drink. She must always be up-right, and in her wheelchair."
Ms Crawford confirmed that Cheryl was measured for the chair when Mr Smallshaw was present.
Giving evidence, Mr Smallshaw said that he was of the opinion that Cheryl should not have been fed in the p-pod chair due to the fact she would not be as up-right when sitting in it, but said he could not recall telling Cheryl's family that.
Coroner Louise Slater said that a review of Cheryl's medical notes and CSCSC care plan revealed that while it was explicitly stated that Cheryl should always be as upright as possible when being fed, there was nothing in her notes or her care plan which said she should not be fed in the p-pod chair.
Mr Smallshaw confirmed that he had not personally requested that it be stated in Cheryl's CSCSC care plan that she should not be fed in the p-pod chair, because he believed it fell under 'the realm' of the centre's own physiotherapist, Caroline Hickson, to update her care plan with that information.
Ms Hickson was not initially asked to give evidence at Cheryl's inquest, but following the testimony of Mr Smallshaw, Coroner Louise Slater, said she felt it was necessary to adjourn the inquest until Ms Hickson could be called as a witness.
Cheryl's inquest is now due to resume in January next year.