Care dwelling resident dies after ‘choking on disposable gloves she bought out of the bin’
A coroner has warned that urgent changes are needed to how surgical gloves are disposed of in care homes after an 83-year-old dementia patient choked to death on used gloves at a care home
Margaret Wilson was a resident at Oakridge Care Home(Image: Google Maps)
A coroner has issued a warning that alterations are required to the protocol for disposing of used surgical gloves in care homes catering to dementia patients.
This follows the tragic death of 83-year-old Margaret Wilson, who died on August 10, 2022, after choking on used surgical gloves she had retrieved from a pedal bin with a lid located in a bathroom at Oakridge Care Home. Ms Wilson, diagnosed with dementia and Alzheimer’s disease, had been a resident at the Ballynahinch care home since May 2022.
Earlier on the day of her death, Ms Wilson was discovered ripping pages from a magazine and putting them in her mouth, marking the first instance of her being seen inserting foreign objects into her mouth. The 83-year-old was known to roam the corridors of the care home and was often restless in the evenings, a recognised and common symptom of dementia.
On Thursday, May 7, 2026, the coroner presented her findings into Ms Wilson’s death during an inquest hearing at Belfast Laganside Court.
The inquest heard from Ms Wilson’s son, Andrew Wilson, who portrayed his mother as a “stalwart” who was “well known and well regarded.” He expressed that the family were pleased with her care at Oakridge Care Home, and were “generally content” with her placement there, reports Belfast Live.
Kelly Kilpatrick, the manager of Oakridge at the time, informed the coroner that staffing levels were set in line with guidelines provided by the Regulation Quality Improvement Authority, also known as RQIA.
On the evening of August 10, 2022, three staff members were on duty; one nurse and two healthcare assistants covering the first floor throughout the night shift, which commenced at 8pm.
Healthcare assistant Louise Wilson stated she noticed Ms Wilson walking along the corridor shortly before starting her shift, and realised she was ripping pages from a magazine and putting them in her mouth. The coroner noted that Miss Wilson handled this situation “appropriately,” by alerting Nurse Badza, with whom she was working.
The coroner stated “it is not clear what steps were taken immediately” by Mr Badza after learning Ms Wilson had been consuming pages from a magazine. Mr Badza recorded the incident in evaluation sheets, but the coroner determined there appeared to be no documented review or assessment of the surrounding environment.
Mr Badza informed the inquest there was no chance to modify Ms Wilson’s care plan to identify any risks linked to her swallowing foreign objects, as she had no previous history of this behaviour until the day of her death.
The inquest was told that Nurse Badza subsequently discovered Ms Wilson leaning against a railing outside the nurse’s station on the first floor of the care home, before he helped her to a nearby chair, where she “quickly became unresponsive.” The coroner determined he properly activated the emergency alarm and called out for help from colleagues, which resulted in the immediate response of two care assistants and the nurse on duty downstairs. He also alerted the emergency services.
Ms Wilson was transferred to the floor for CPR, with the coroner acknowledging that Miss Wilson tilted the deceased’s head backwards to examine her airway and spotted a blue object lodged at the back of her throat. Miss Wilson then extracted what turned out to be a pair of blue surgical gloves, which had been utilised owing to the way they were bundled together.
While it cannot be established precisely where Ms Wilson obtained the used gloves, the coroner determined “on balance” she is satisfied they were taken from a lidded pedal bin situated in a bathroom on the first floor of the care home.
CPR attempts continued for a “considerable period of time” with a defibrillator also utilised by care home staff. A “do not resuscitate” directive had been placed on Ms Wilson’s file before her admission to Oakridge Care Home, and it remained unclear whether this was still in place.
Nevertheless, the coroner ruled the resuscitation efforts undertaken by staff were “appropriate, reasonable, and necessary” in what “cannot be considered a naturally occurring event.” Following resuscitation attempts by both care home staff and paramedics, Ms Wilson’s life was tragically declared over at 11.20pm on August 10, 2022. The coroner determined her death resulted from asphyxia caused by choking on surgical gloves.
After Ms Wilson’s death, surgical gloves at Oakridge Care Home are now kept in locked cupboards along the corridors, which can only be accessed using a magnetic key. The coroner praised this measure for reducing risks, but emphasised that the procedure for disposing of used gloves “remains unchanged” and they continue to be thrown away in pedal bins.
The coroner has demanded alterations to this protocol, and plans to write to the relevant authorities to highlight this.
She said: “I acknowledge that this is compliant with the applicable regional protocol for waste disposal and is deemed necessary for infection control. However, it is wholly conceivable that such an incident could occur again in the future, whereby a resident in the care home could remove items from a bin and place them in their mouth, which could potentially lead to choking and possible death.
“I therefore intend to write to both the Department of Health and RQIA, including a copy of these findings, with a view to highlighting the risks associated with little pedal bins as a waste disposal system, particularly to patients suffering from dementia, and urge them to consider implementing and utilising a safer method of waste disposal in residential units where patients with dementia reside.”
The coroner concluded the inquest by extending her condolences to Ms Wilson’s family.
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