Bipolar woman died after choking on cake still in its plastic wrapper, inquest hears

Fenella Esson was detained at Gosport War Memorial Hospital with severe bipolar affective disorder with episodes of mania and psychosis. She suffered a cardiac arrest after choking on the plastic-wrapped piece of cake and attempts to help her failed.

Fenella died aged 66 two days later at Queen Alexandra Hospital in Portsmouth on 20 July 2020 having suffered from severe hypoxic ischaemia, which left her with irrecoverable brain damage.

A jury returned a conclusion of death by misadventure following a five-day inquest held from 7 – 11 April 2025 at Winchester Coroners Court.

HM Senior Coroner Chistopher Wilkinson noted that, although it was unlikely to have caused or contributed to Fenella’s death, steps should be taken to improve communication between hospital trusts to ensure faster arrival of appropriate emergency care in future scenarios.

Nurses, paramedics, and other healthcare professionals gave evidence at the inquest where Fenella’s family raised concerns over the nurses’ response to the choking, including the quality of the CPR provided, the communication with the emergency services, and the failure to liaise with paramedics. 

Fenella had a long history of mental health issues. Her primary diagnosis was bipolar affective disorder with likely schizoaffective disorder. She was detained under Section 3 of the Mental Health Act 1983 at the Gosport War Memorial Hospital in July 2020, after experiencing worsening confusion, hallucinations, and delusional thoughts. She was kept in her own room on the ward, with observations every 15 minutes.

On the morning of 18 July, staff served Fenella a cup of tea and a slice of cake, which was served in a plastic wrapper, then left the room. 

For reasons unknown, Fenella put the whole cake, wrapper included, into her throat. Her coughing reflex attracted the attention of nurses and healthcare support workers outside her room, who rushed in and attempted to help by administering back slaps and abdominal thrusts, which were unsuccessful.

The inquest heard that emergency services were contacted, but the ambulance was initially dispatched as a Category 2 call, rather than the highest-priority Category 1.

Fenella lost consciousness and went into cardiac arrest. CPR was commenced by nursing staff, but the inquest heard concerns about the quality of chest compressions being delivered. A paramedic reported finding staff delivering one-handed compressions while standing, which the paramedic considered to be ineffective. An expert emergency medicine consultant, instructed to advise the coroner, commented that, in his opinion, “the quality of CPR received by Ms Esson was poor”.

The inquest heard further delays occurred as neither of the two paramedics dispatched were met at the hospital entrance and they each had to find their own way to the ward.

The first paramedic removed the plastic-wrapped cake from Fenella’s airway using forceps. Fenella was transferred to Queen Alexandra Hospital in Portsmouth. She died two days later, on 20 July 2020, due to severe hypoxic-ischaemic brain injury.

Although the emergency medicine expert concluded that Fenella’s chances of survival would have remained very low even if the CPR had been of “optimal quality”, and the emergency response had occurred within the most “optimal timeframe”, the coroner noted potential areas to improve to minimise the risk of future deaths. He expressed concerns about the hospital’s training and the staff’s initial emergency response, including the communication with the emergency services and the failure to meet paramedics. He has called on Hampshire and Isle of Wight Healthcare NHS Foundation Trust and South Central Ambulance Service NHS Foundation Trust to improve joint communications to avoid similar delays in emergency situations.

Fenella’s brother, Matthew, was represented by Michael Roberts, medical negligence solicitor at law firm Leigh Day, and barrister Nicholas Jones of One Crown Office Row chambers.

Michael Roberts said:

“The circumstances of Fenella’s tragic death highlight the importance being adequately prepared for catastrophic events in a community hospital setting. Although in Fenella’s case, there was sadly little that could have been done to prevent her death, we hope that this inquest, and the coroner’s recommendations, will greatly reduce the risk of a future tragedy occurring in this manner.”

Matthew said:

“I would like to record my thanks to Leigh Day's legal team of Michael Roberts and Izzy Hawkins - backed up by Nick Jones, Counsel from 1 Crown Office Row chambers. This small group of youthful, energetic and highly capable lawyers made the week much more productive, also much less painful than it could have otherwise been.

“I would also like to thank the coroner for his forensic attention to detail, thoroughness and also for his sensitivity and compassion. I also thank the jury for their impressive and sustained powers of concentration, listening skills, as well as their spirited engagement with the proceedings.

“It was also gratifying that the coroner was prepared to look at issues outside the immediate facts of the case, specifically the poor quality of communication between the Trust and Fenella's family, evidenced well by the failure of the Trust to acknowledge my sister's death, which I felt was not only insensitive, but discourteous. This omission, it transpired, was due to an administrative error, which caused her death to be categorised as an 'incident of low harm'. Thankfully, following assurances from the Trust's Chief Executive, this sort of error is unlikely to be repeated.”