Grandmother choked to death after being fed porridge by an agency nurse who went on a break

An elderly woman choked to death in her hospital bed because she was given a spoonful of porridge and then deserted by a nurse keen to go on her break.
Margaret Walker, 86, was admitted to Warwick Hospital after a fall and was being cared for on the hospital's Beaumont ward.
But her family have blasted what they call 'lack of dignity and respect' after she died because nurse Geraldine Pettipher gave her a spoonful of porridge and left her unsupervised.

Must improve: Warwick hospital was told if had 28 days to show the court and Mrs Walker's family evidence that improvements had been made

The Coroner's court heard that on the morning of February 2 this year Ms Pettipher and another senior nurse Aurora Gherman had been worried about Mrs Walker and had called a doctor to see her before breakfast.
But both nurses decided the Mrs Walker was not at risk of choking and did not notice that  she went pale and her breathing became irregular after eating the porridge.
Ms Pettipher, a nurse from an outside agency providing shift cover, then went on a break and Ms Gherman left the room.

But by the time a doctor arrived, Mrs Walker, from Stratford-upon-Avon, Warkshire, had choked to death.
Tragically, the inquest heard the grandmother died just yards away from suction equipment that could have been used to save her life if there had been enough staff to notice that she needed it.
Giving evidence at the inquest at the Warwickshire Justice Centre in Leamington Spa Ms Pettipher said she was told to go on her break by Ms Gherman.
But the senior nurse disagreed saying she would not have told anyone to go on their break that early in the shift.
Ms Pettipher said: 'I heard her swallow it (the porridge), and as soon as she did she became pale and her breathing became irregular.'

Mrs Walker's son David told the inquest that the poor standards of care at the hospital contributed 'directly and indirectly' to her death (picture posed by models)

Warwickshire assistant coroner David Clark expressed concerns about a catalogue of communication errors leading up to Mrs Walker’s death.
Ms Pettipher, who works in hospitals all over the country, said she had previously had difficulties getting a doctor to attend patients on the Beaumont Ward and that she was never properly inducted onto the ward.
She said: 'If I work in an area I am normally given an induction, shown where the crash trolley is.'
When the coroner asked if her experience at Warwick Hospital differed to that of others, she said: 'Yes, it did differ.'
She also told the inquest she had been told Mrs Walker’s cancer had spread but a post-mortem showed no signs of this.
Mrs Walker's devastated son David, 54, said he was concerned that staff did not know basic information about his mother's condition and that she had been labelled a ‘do not resuscitate’ (DNR) patient.
Speaking at the inquest he said: 'Ms Pettipher was told it had spread, and that must have contributed to any decision not to resuscitate.
'We are not sure if she was assessed properly, most of the nurses did not understand that she had hearing difficulties.'
Mr Walker told the coroner that the poor standards of care at the hospital led both 'directly and indirectly' to his mother’s death.
He added: 'Directly, I think if she had been responded to in that 15-20 minutes by another nurse she would not have died.
'Indirectly, her general state of health deteriorated during her stay in hospital because she wasn’t particularly well looked after.'
After recording a narrative verdict, Assistant Coroner Mr Clark wrote a formal letter to South Warwickshire NHS Foundation Trust demanding assurances that lessons had been learnt from Mrs Walker’s death.
He said he was particularly 'uncomfortable' with the quality of communication between agency nurses and hospital nurses.
The trust was given 28 days to provide the coroner and Mrs Walker’s family with evidence of the improvements that have been made to their induction process for agency nurses.
A spokesperson for the trust confirmed a full investigation had been conducted.
She said: 'The trust’s investigation found that some elements of record keeping should have been better and this is something that the trust has placed a lot of emphasis on with our nursing teams.'
Speaking on behalf of the family after the inquest, Mr Walker said: 'Margaret was a loving mother and grandmother and is sadly missed.
'We are very disappointed to find out the extent of the poor nursing care and lack of dignity and respect shown to Margaret.
'The family are pleased the inquest has finally been concluded and note the coroner has written formally to South Warwickshire NHS Foundation Trust regarding various specific procedures at Warwick Hospital.'

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