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A care home patient choked to death on a jam doughnut despite a warning she should not be given bread, an inquest has heard.
Christine Thomas, 59, was handed the snack cut into three pieces by agency care worker Paula Parry, while taking lunch at the Swn y Wylan Home in Rhos-on-Sea, North Wales.
When Ms Parry returned from fetching a napkin, she noticed the patient, who had physical and mental health problems, ‘looking grey’ and with blueish lips but she did not seem to be choking, the inquest in Ruthin, Wales heard.
Paramedic Richard Roberts said he removed ‘a small particle of food’ from Ms Thomas’s airway.
Lynne Forbes, manager of the home, said she first found out about the doughnut incident a day later, when the care home patient had been admitted into intensive care.
Ms Thomas, who had stayed at Swn y Wylan for 25 years, died at Glan Clwyd hospital in February 2023, three weeks later.
An inquest heard her care plan had clearly stated ‘no bread’ due to the risk of choking, but Ms Forbes told the coroner the document, drawn up a year prior, did not refer specifically to doughnuts.
The manager of the care home said: ‘That is more of a cake with jam.’
Ms Parry said she thought she could give her the sliced up doughnut because she knew she had previously eaten mashed potato and pasta.
She added that her training had not covered dysphagia – difficulties with eating – and she believed she should have been made aware of the details of her care plan.
The care worker said that a colleague had remained with Ms Thomas while she went to get the napkin.
The cause of death was given as hypoxia – lack of oxygen to the brain – due to cardiac arrest caused by choking.
Assessments into Ms Thomas’s eating ability were carried out in 2018, 2021 and 2022.
The inquest heard steps had since been taken to improve staff training at the care home, which is part of the Coed Du Hall group.
A coroner recorded a conclusion of misadventure.
John Gittins, senior coroner for North Wales East and Central, said: ‘It is probable that carers were not properly conversant with the care plan, due to inadequate training.’
He said the matter had also been referred to North Wales Police to consider whether a criminal offence had been committed, but no further action was taken.
