Care resident choked on jam doughnut, inquest hears

The care worker was not aware there was an instruction not to give the patient any bread products

A care home resident whose care plan stated "no bread" died after being given a jam doughnut, an inquest heard.

Support care worker Paula Parry said no one at the home in Rhos-on-Sea told her this instruction in relation to resident Christine Thomas.

A care home manager told the inquest the care plan did not specifically refer to doughnuts, but added that the dessert was "more of a cake with jam".

The part-heard inquest has been adjourned to a date yet to be fixed.

Miss Thomas, 59, had mental and physical health problems and was a resident at the Swn-yr-Wylan Home when the incident occurred on 13 January.

Mrs Parry, an agency worker, told the inquest she broke the doughnut into small pieces and gave Miss Thomas three, all with jam on them, before she collapsed.

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Mrs Parry wiped away tears as she told the Ruthin inquest that another care worker was at Miss Thomas's side as she fed her, but after going to fetch a serviette she saw Miss Thomas "looked grey" and her lips were blueish.

She did not appear to be choking, however, but her eyes were rolling and Mrs Parry thought she was having a heart attack.

Staff carried out CPR and paramedics managed to restart her heart.

Miss Thomas was taken to Glan Clwyd Hospital but died on 4 February.

Asked by Kate Robertson, assistant coroner for North Wales East and Central, whether she was aware of the clear note in Miss Thomas's care plan, Mrs Parry said she felt her attention should have brought to it.

But she continued: "She ate mashed potato and pasta."

Ms Parry said her training had not covered issues such as dysphagia - difficulties with eating - and felt that there was nothing wrong in giving her two or three small pieces of doughnut with jam on them.

"If she had appeared to be choking I would have dealt with it as a choking incident but there didn't appear to be an obstruction," added Ms Parry.

Paramedic Richard Roberts said he removed "a small particle of food" from Miss Thomas' airway.

Lynne Forbes, manager of the home, which is part of the Coed Du Hall group, said the first she knew of the doughnut being given was the day after the incident when Miss Thomas was in intensive care.

Asked by the coroner whether she accepted that giving Miss Thomas even a small piece of doughnut did not comply with her care plan, Mrs Forbes said the plan did not refer specifically to doughnuts.

"That is more of a cake with jam," said Ms Forbes.

Asked what lessons had been learned from the incident, Mrs Forbes said that training had been improved and more attention was being paid to care plans.

Adjourning the part-heard inquest to a date to be fixed, the coroner said she needed to consider whether to issue a Prevention of Future Deaths notice.