Coroner's Finding: MANN Richard Lesley

45y · Male·choking on food

Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and monitoring preceded his death: he received wrong medications (Thyroxine and Carbamazepine) administered through breached medication protocols; was restrained inappropriately with medical tape during showering; and suffered a fall with head injury immediately after restraint removal. Rather than triggering heightened observation, these incidents were inadequately documented and monitored. The coroner found that close neurological observations following the head injury would likely have prevented the fatal choking episode. Key systems failures included: breach of medication dispensing protocols, lack of clear command structure between nursing and care staff, absence of proper escalation procedures, and failure to maintain safety observations after a documented traumatic incident.