Tap above to watch video report by Sam Holder
A coroner has criticised a care home over its “significant management failure” after a patient choked to death on a marshmallow.
Patrick Casey, 41, died on April 5 2019 at Barnet Hospital after he was found unresponsive at Devon House care home in north London.
An inquest at North London Coroner’s Court heard Mr Casey had been fed marshmallows by care workers despite being on a strict pureed diet.
Senior coroner Andrew Walker highlighted the importance of having a named individual at a care home who is responsible for ensuring a patient’s medical and care plan needs are being met.
He said: “The registered manager in this case was completely unaware that staff were providing to Mr Casey foodstuff that was potentially fatal to him.”
He added: “The general understanding by care staff was Mr Casey could be given marshmallows cut into pieces.
“This view was formed without any professional input by a speech and language assessment.
“This view was honestly held by care staff.”
He said staff at Devon House care home, which has since closed, had a “limited and flawed” understanding regarding Mr Casey’s food, and “this was not corrected or checked at management level”.
Giving a narrative conclusion at the end of the inquest on Monday, he said Mr Casey died as a consequence of choking on food following a failure to follow the dietary requirements.
Speaking directly to Mr Casey’s family at the virtual hearing, he said: “This was an avoidable death, an unnecessary death, you were quite right in everything you said from the time you first stepped into this court.”
A member of Mr Casey’s family could be heard saying “he can rest in peace now”.
During the inquest, Claire Twyford, service manager at Devon House, said in her evidence to the court that she was not made aware of Mr Casey being fed marshmallows that were “cut up in small pieces” by care staff until after he had died.
Mr Casey’s sister, Mary Casey, told the hearing she “flipped out” and scolded care staff after finding an open packet of the soft sweets in his bedroom on March 17 2019.
Ms Twyford said she had not been at the care home during this incident and that Mr Casey’s family had not raised concerns about him choking to her, adding that if they had she would have acted on them “as soon as reasonably possible”.
When asked what she would have done had she seen marshmallows in Mr Casey’s room, a teary Ms Twyford said: “I would have removed them, I would’ve asked the staff why they were there and make sure there was communication not to have them.”
On the day of Mr Casey’s death, the inquest heard there was one agency nurse on duty who had never worked at the care home before and did not undergo an induction.
The inquest heard Mr Casey was found by support workers in his room limp in his wheelchair with marshmallow “dripping from his mouth” and in his hand, and an opened bag of marshmallows within his reach. Birmingham-born Mr Casey had been a resident at the Priory Group-run care home since 2014 and used a wheelchair after suffering a serious brain injury when he was struck by a car in 2005.
The court heard Mr Casey would not have been able to open the bag of sweets himself.
Ms Twyford said she had been on secondment at another care home in High Wycombe for most of 2019 and agreed there was “confusion at the time of the chain of command”.
The inquest heard care workers who found Mr Casey unresponsive waited for permission from the nurse before administering first aid, which Ms Twyford said was a misunderstanding among staff.
Activity co-ordinator Eleanor Powell told the inquest she would buy marshmallows for Mr Casey to eat as it was “already a general culture when I arrived there”.
A medical cause of death has been given as choking, aspiration (inhaling food into airways) and acquired brain injury.
Referring to him by his nickname of Wacker, Mr Casey’s sister said he was “one of the best people I knew”.
In a statement following the inquest, she said: “He was such a caring, kind soul and we miss him every day.
“We are glad that the circumstances of my brother’s death have been investigated and made clear in the inquest.
“I made it very clear to staff at Devon House that he could not have marshmallows.
“It was this that led to him choking to death weeks later.
“We are convinced his death should not have happened and the sadness of losing my brother will remain with us always.
“Following the coroner’s conclusion we hope that changes are made urgently in order to prevent similar tragedies from happening.”