A CORONER said there had been an ‘absence of professional curiosity’ as he concluded the inquest of a woman who died after swallowing her dentures a week earlier.

Valerie Keeble, 90, had complained to care home staff and her GP of having swallowed a tooth after she choked on a sandwich at The Grange nursing home in Stanford in the Vale on September 4, 2020.

Her family, who told the coroner they felt Mrs Keeble was ‘grossly let down’, had raised concerns about her missing dentures and queried whether she might have swallowed them.

Oxfordshire Coroner’s Court heard that an examination of Mrs Keeble’s mouth had been made by a nurse following the choking incident.

A GP had not repeated the oral examination as he was concerned about the dangers of transmitting the coronavirus and an earlier check had been done, although he recorded in his notes that the only way to check if her throat was blocked would have been potentially invasive hospital procedures.

Senior coroner Darren Salter told the inquest: “One tries to avoid the benefit of hindsight. I’ve already referred to that, but even so, even taking that into account and even at the time not with hindsight, the problem that was being faced was [affected] by communication difficulties, lack of clarity and what I might describe in some respects as an absence of professional curiosity on the part of some of those involved around this incident on September 4, commencing with an acute event eating a sandwich and starting to cough and choke.

“She’d said on September 4 and September 7 she’d swallowed a tooth. The dentures were missing and couldn’t be found. As time went on she deteriorated and the question of whether she’d swallowed the dentures should have been given more serious consideration, particularly as it was a concern raised by the family.”

Oxfordshire Coroners' Court

He acknowledged Mrs Keeble’s symptoms were consistent with a chest infection and pneumonia, but added: “It seems to me there were symptoms consistent with partial airway obstruction and in my preparation for the inquest simply Googling ‘swallowing dentures’ brings up references to and papers on previous cases particularly involving partial dentures.”

Mr Salter said he did not feel it would have been possible to see the dentures unless Mrs Keeble were taken to hospital for further investigations. GP Dr Kerrin Masterman said that would have involved at the least an X-ray and probably an endoscopy under general anaesthetic.

The coroner recorded a narrative conclusion. Mrs Keeble’s primary cause of death was given as dehydration.

Valerie Keeble Picture: FAMILY HANDOUT

The Grange nursing home Picture: GOOGLE

The two-day inquest at County Hall heard that Mrs Keeble had been a resident at The Grange care home after suffering a stroke in 2018. She would regularly be looked after by family members during the day, although her visits home had stopped during the pandemic. 

On September 4, a nurse at the home had fitted her dentures securely. While eating a sandwich at the care home she had begun choking. The deputy manager, Harald Traje, conducted an oral examination. 

She complained of having swallowed a tooth but did not repeat this complaint after September 7. In the week that followed, care home staff and her family were unable to find the dentures.

READ MORE: 'Heartbroken' family pay tribute to Mrs Keeble

It was not thought possible by the healthcare professionals that she could have swallowed the bulky false teeth, although Dr Masterman had thought it was a ‘slight possibility’. 

An out of hours emergency practitioner, Leanne Aspinall-Wade, said she was not told about the swallowed tooth. She would have conducted an examination of her mouth if she had been, she told the inquest.

Speech and language therapist Lindsay McKeever, who examined Mrs Keeble on September 8, did not do an oral examination as she thought a single tooth would have passed through her system by then. 

She was not aware her patient’s dentures were still missing and told the inquest that she’d never come across a situation where someone had swallowed their false teeth. Ms McKeever would have expected significant symptoms in someone who had swallowed dentures, which Mrs Keeble did not have. 

Her mouth had been suctioned and there was no evidence of the equipment coming into contact with the dentures. 

Mrs Keeble’s condition was said to have improved around a week after she’d choked on her lunch, before deteriorating again. She died on September 16.

The dentures were discovered in her throat after Mrs Keeble's death.

Giving evidence on Thursday morning, GP Dr Masterman said he had weighed up the risks of further examination of his patient’s mouth and throat. 

Those included the coronavirus pandemic. During the first wave of the virus the care home had lost ‘somewhere between 25 to 30 per cent of its residents in two to three weeks’, he said. “This is something that can spread incredibly fast and is incredibly dangerous for this group of patients.” 

Mrs Keeble had been clear that she did not want to go to hospital, which is where tests like an X-ray and an endoscopy would have to be conducted. 

The health professionals who gave evidence expressed their condolences to Mrs Keeble’s family.

Reports had been prepared in the wake of Mrs Keeble’s death by Oxford Health, the Care Quality Commission and the White Horse medical practice, detailing lessons to be learned.