Care home resident died after choking on piece of pork, inquest finds

David, a resident at Dormy House in Sunningdale, Berkshire, had Parkinson's Disease and had recently been diagnosed with dementia.

On Sunday 15 October 2023 he choked on a piece of pork while eating his lunch. He was transferred to St Peter’s Hospital in Chertsey but never regained consciousness. He died on 18 October 2023.

An inquest into David’s death was held on Monday 11 November 2024 at Berkshire Coroners Court.

Senior Coroner Heidi J Connor recorded a conclusion of accidental death contributed to by natural causes, those being dementia and Parkinson’s Disease.

David was served his lunch in the lounge rather than in the main dining room on the day of the choking incident. A care assistant told the coroner that during lunchtime that day she was working between two rooms to help a resident who could not eat on his own while serving food to others.

She told the inquest that she did not know David but was told by another carer that he did not need assistance to eat. She had not read his care plan.

The inquest heard the care assistant cut up the food on David’s plate. She explained to the coroner that she had noticed that the roast pork was “not very soft” but did not raise her concerns and left him to eat on his own.

A short time later, a nurse entered the room and found David slumped over with his plate of food in front of him. She asked him if he was okay, but David’s response was muffled. She described to the coroner that she knew straight away that he was choking, before shouting out to the care assistant to raise the alarm.

The inquest heard how staff attempted back slaps and abdominal thrusts, but David continued to choke and became unconscious. Staff phoned 999 and were instructed to carry out CPR and chest compressions.

When the paramedics arrived they removed a piece of pork from David’s airway with ‘minimal difficulty’. The coroner and all the witnesses agreed that the piece of pork removed from David’s airway was not bite sized.

During the inquest, the coroner also raised concerns over the factual inconsistencies within statements taken from members of staff.

Following an unannounced CQC inspection five days after David’s death, on 23 October 2023, the home, managed by Aria Care, was rated ‘inadequate’ in a report published in January 2024. 

The inspection found the management of people at risk of choking was not always done in a safe way. It also noted a risk of residents being given food that was not suitable for them to eat. 

David’s daughter Jane Stuart is represented by Beatrice Morgan, a human rights solicitor at Leigh Day.

Jane Stuart said:

“To lose Dad in this way has been deeply distressing. We trusted Dormy House to care for Dad when he was in need of extra support. Serving appropriate food for elderly people seems a basic requirement of a nursing home. Dormy House failed to do this. I’m concerned the coroner discovered factual inconsistencies within the witness statements taken from members of staff. It saddens me that they could not take responsibility for their failings on that day. It is vital that these corporates have accountability for the services they are paid to provide. Dad should not have died in this way.”

Beatrice Morgan said:

“David’s death was a tragedy that should not have happened. If he had been given food that wasn’t so tough, if it had been cut up into smaller pieces or if he hadn’t been left by himself the outcome would have been very different. It is extremely concerning that when the CQC visited Dormy House a week later, the safety of residents during mealtimes still had not been prioritised. We hope that Aria Care has learnt lessons and has taken steps to protect residents in all its care homes from the risk of choking.”