A nursing home nurse who performed ‘ineffective’ cardiopulmonary resuscitation (CPR) on a woman with swallowing difficulties who was choking to death had been insufficiently trained – and was the only staff member to have valid life-support training. A coroner’s report pointed to lack of essential information-sharing at Mandeville Grange Nursing Home in Buckinghamshire about Sheila Nicholls’ swallowing difficulties, resulting in her being served toast for breakfast. Relatives had informed the home of the choking risk but this information was not passed to staff caring for her. The coroner said neglect had been a factor in Ms Nicholl’s death. He was critical of two internal investigations the nursing home subsequently conducted and warned of future risk of fatality if staff are not given adequate training.