Inquest into the death of Rashida Sultana, 76 exposes confusion over DNAR orders at Sandwell and West Birmingham Hospitals NHS Trust

The issues were heard during the inquest into her death at Black Country Coroner’s Court in Oldbury on 1 and 2 October 2025. It concluded that Ms Sultana died as a result of choking on 19 November 2024. 

The coroner found there was confusion and a lack of understanding among staff about whether Emergency Medical Response Team (EMRT) should be called when a DNAR order is in place. He will issue a Prevention of Future Deaths (PFD) report to Sandwell and West Birmingham Hospitals NHS Trust. 

Ms Sultana was admitted to Midland Metropolitan Hospital, part of Sandwell and West Birmingham Hospitals NHS Trust, on 18 November 2024 following concerns that she had suffered a stroke. The next day, a DNAR and “Not for EMRT” (Emergency Medical Response Team) instruction were added to her medical records. Her family told the inquest they did not agree with this decision, but were overruled by a doctor who cited Ms Sultana’s frailty. 

Ms Sultana had a diagnosis of advanced dementia.  Whilst not clear, it appeared that Ms Sultana may have suffered a minor stroke, which would not have shown on a CT scan.  There was evidence of facial drooping and dribbling, but these were not documented in her medical notes.  

The inquest heard that staff did not identify her increased risk of choking and did not refer her for a Speech and Language Therapy (SaLT) assessment. An occupational therapist gave evidence that they were unaware dementia patients are at heightened risk of dysphagia, a condition affecting swallowing. The OT also stated they were not aware that Ms Sultana had been dribbling water earlier, which is also a red flag for swallowing issues. They confirmed that, had they been aware of this, they would have made a referral to the SaLT.  

On the evening of 19 November, Ms Sultana’s family brought food into the hospital for her to eat. After taking a sip of water, she began to cough and gulp. Nurses attempted back blows and suctioning, but these were unsuccessful. A nurse then used the hospital’s internal paging system (known as the bleep system) to call a doctor. However, the inquest heard that this system is not intended for emergencies. In such cases, staff should instead call EMRT. 

The doctor who received the page did not attend, as they were treating another patient. The nurse then called EMRT, but told the coroner they were unaware this should have been done immediately. They were under the mistaken belief that the Not for EMRT instruction meant EMRT should not be contacted in reversible emergencies such as choking. 

EMRT arrived approximately 40 minutes later. By that time, Ms Sultana had died.  

Ms Sultana’s family raised a formal complaint with the Trust. They cited failures to carry out a SaLT assessment or swallowing risk assessment following their mother’s admission and test results on 18 November. They also expressed concern that emergency treatment was not provided and that escalation to EMRT was delayed. 

A Serious Incident Review later stated that Ms Sultana’s death was probably avoidable, though this view was reversed after internal discussions. 

The coroner, Mr Zafar Siddique, reached a short narrative conclusion that Ms Sultana died after choking on food she was eating in hospital. 

Whilst the coroner did not find that Ms Sultana’s death could have been prevented if EMRT had been called immediately, he did record that there was a lack of clarity in the hospital’s policies regarding when to escalate a patient to EMRT in emergency situations, particularly where DNAR orders are in place. He also recorded that during her admission, it wasn't deemed a speech and language therapy assessment was required despite her risk of dysphagia from dementia. 

Due to ongoing concerns about EMRT and DNAR protocols, the coroner will issue a Prevention of Future Deaths (PFD) report to the trust, requesting further explanation and action. 

Ms Sultana’s daughter Rizwana Kausar is represented by Izzy Piper and Tiffany Bucknall, solicitors at law firm Leigh Day. 
 
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.”