Teresa Pokoyski neglected before death, inquest finds

Teresa May Pokoyski was completely dependent on care home staff

Neglect played a part in the death of an 85-year-old at a care home, an inquest found.

Teresa Pokoyski died after choking at the Gnoll care home, Neath, in 2012.

An inquest following her death found the primary cause was pneumonia caused by lung cancer.

Her family believed food particles in her lungs due to poor feeding practices led to her death, and challenged the original decision, with a new inquest held at Pontypridd Coroner's Court.

Assistant Coroner for South Wales Central Sarah Richards said there was a clear or direct causal connection between neglect and Mrs Pokoyski's death.

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A new cause of death was recorded as aspiration pneumonia and sepsis, with multiple strokes a secondary factor and adenocarcenoma (cancer) as the third factor.

The coroner said she would not be making a prevention of future deaths report.

Mrs Pokoyski was wholly dependent on staff for her daily care and following a brain haemorrhage in her thirties and strokes in later life could only be fed pureed food with a teaspoon, the inquest heard.

She had to be fed in an upright position due to the risk of inhaling food.

Mrs Pokoyski's family made a sign to put above her bed so staff would follow guidance

The coroner heard concerns from the family that strict guidance about feeding Mrs Pokoyski was not followed and that she was sometimes fed in a reclining position and was not always given pureed food.

A post mortem examination report showed that inhaling food had been happening for months rather than being an isolated incident which led to Mrs Pokoyski being taken ill in October 2012.

The original inquest had given the cause of death as pneumonia as a result of lung cancer.

But her family were concerned that aspiration, or inhaling food, had caused her death, with daughter Diane Hopkins saying she was happy with the outcome of the second inquest.

She said it was what they had been fighting for for 11 years, adding: "We've got justice for her."

Ms Hopkins added she would be writing to the older people's commissioner about the care home.

In a statement, Gnoll Nursing Home said: "These events happened 11 years ago and many witnesses were not available for the inquest. Mrs Pokoyski's care needs were complex and she was always at risk of aspiration pneumonia.

"All lessons that could have been learned have been learned and the decision not to issue a prevention of future deaths order reflects that current practices are fully compliant.

"The delay in these proceedings has been very difficult for Mrs Pokoyski's family and the care home staff. We are glad to be able to draw a line under the event and offer our sincere condolences to Mrs Pokoyski's family."