“The inquest heard evidence from , Director of Operations for 1st Care Limited, the…”
Dated 24 Jan 2025, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Mar 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated24 Jan 2025
- Deadline21 Mar 2025
- Published on judiciary.uk27 Jan 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Birmingham and Solihull Integrated Care BoardNamed in the report as “Birmingham and Solihull Integrated Care Board” | Response publishedPublished on judiciary.uk in January 2025. |
| The Health and Safety Executive | Response publishedPublished on judiciary.uk in January 2025. |
The coroner’s concerns
– 1. The inquest heard evidence from , Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available. 2. , who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home. 3. I heard evidence that the devices are relatively inexpensive and do not require extensive training. 4. ' evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths. 5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0044
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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