Hospital death inquest highlights confusion over DNAR orders
Rashida Sultana, who had advanced dementia, died after choking on food at the Midland Metropolitan Hospital on 19 November 2024
Last updated 3rd Oct 2025
Serious concerns have been raised about how “Do Not Attempt Cardiopulmonary Resuscitation” (DNAR) orders and emergency procedures are handled at Midland Metropolitan Hospital, following the death of seventy six year old Rashida Sultana.
Ms Sultana, who had advanced dementia, died after choking on food at the hospital on 19 November 2024.
An inquest at Black Country Coroner’s Court heard that staff were unclear about whether they could call the Emergency Medical Response Team (EMRT) because a DNAR instruction was in place.
The confusion led to delays in getting emergency help, with the EMRT only called around forty minutes after Ms Sultana started choking.
The coroner found there was a lack of understanding among hospital staff about when to escalate emergencies in cases involving DNAR orders.
He also highlighted missed opportunities to assess Ms Sultana’s swallowing risk, as no Speech and Language Therapy referral was made despite warning signs.
Ms Sultana’s family had disagreed with the DNAR decision, which was made due to her frailty, but were overruled by hospital doctors.
Following her death, the family complained to Sandwell and West Birmingham Hospitals NHS Trust about failures to identify and address her choking risks and the delay in emergency response.
The coroner will issue a Prevention of Future Deaths report to the trust, calling for clearer policies around DNAR and emergency escalation, particularly for vulnerable patients.
In a statement, following the conclusion of the inquest, Ms Sultana’s family said: “Mum was deeply loved by everyone who knew her and has left a lasting impact on all our lives. We cannot begin to express the pain and sorrow we feel over her death, especially knowing the circumstances in which she suffered and died.
“We believe there were multiple missed opportunities in her care, starting from the moment of her admission. The hospital failed to recognise her increased risk of choking due to her advanced dementia and did not consider conducting a capacity assessment to determine whether she could make decisions about her care.
“Had the SaLT assessment been carried out earlier, we as a family could have been more mindful of her dietary needs and better able to monitor her food intake.
“Our mother’s high risk of dysphagia was overlooked by all professionals involved in her care. We feel this critical oversight, compounded by the failure to escalate her condition to the EMRT, ultimately led to her death. She was in the care of the NHS and its clinicians, and they let her down.
“As a family, we are deeply concerned about the lack of clarity surrounding when EMRT should be called for patients with a Do Not Attempt Cardiopulmonary Resuscitation in place. The inquest revealed that existing policies provided insufficient guidance on this issue.
“We question why it took our mother’s death for these shortcomings to be identified, reviewed, and addressed. We welcome the coroner’s PFD report on this matter.”
Leigh Day solicitor Izzy Piper said: “Ms Sultana’s death raised serious concerns about the care provided to vulnerable patients in hospital settings, particularly those with advanced dementia.
"The inquest heard evidence about the lack of awareness of the increased risk of dysphagia for people with advanced dementia, as well as the misunderstanding around emergency response protocols.
“This case highlights the need for clearer guidance and training around DNAR and not for EMRT decisions, dysphagia risk in dementia patients, and escalation procedures in emergencies. Ms Sultana’s family hope that lessons will be learned to prevent similar tragedies in the future.”
In response, Chief Medical Officer at the Sandwell and West Birmingham Hospitals NHS Trust, Dr Mark Anderson, said: “We extend our deepest condolences to the family of Mrs Sultana, whose death in November 2024 was a deeply distressing event for all involved.
“Following a comprehensive review of the circumstances surrounding her death, we have implemented a number of measures to ensure this incident does not happen again, most importantly reinforcing the importance of calling the Emergency Medical Response Team (EMRT) immediately in the event of a choking incident.
"This protocol now applies regardless of a patient’s resuscitation status, recognising that some emergencies may be reversible. Our staff have received updated guidance and training to clarify the appropriate response to medical emergencies, particularly in cases involving DNACPR orders. This includes ensuring that staff understand when emergency intervention remains appropriate.”