The death of a retired banker at a Sidmouth residential home could have been prevented if he had received the correct professional care, a coroner has concluded.
Geoffrey Burnand died in November 2012 after choking on a piece of meat at Arcot House, which was at the time operated by Guinness Care and Support.
An inquest heard that issues with staffing and a failure to update the 84-year-old’s care plan were ‘key issues’ in his death.
Mr Burnand, who suffered from Alzheimer’s dementia, choked on a piece of roast beef while eating lunch on November 18, 2012.
He was taken to the Royal Devon and Exeter Hospital where doctors concluded he had suffered brain damage due to a lack of oxygen.
He died on November 19.
The inquest was told that on the morning of November 18, 2012, three junior staff, one of which was acting as a senior carer, were on duty at Arcot House.
The inquiry heard evidence that the correct staffing level for a morning shift at the home in Arcot Gardens was one senior carer and three juniors.
One of the carers was an agency worker, on her first shift at Arcot House in a year.
She was the only member of staff in the dining room when Mr Burnand suffered the choking incident, and had not been told he suffered from Alzheimer’s.
Andrew Cox, assistant coroner for Exeter and Greater Devon, said: “She simply could not provide the close observation that Arcot House in its own records said had to be provided. That was not her fault - it was a system failure.”
The inquest heard that Mr Burnand’s dementia may have affected his ability to swallow properly - and he had suffered a separate serious choking incident earlier in November 2012.
However, this had not been recorded in his care plan – a document outlining the specific needs of residents. Following the incident, Mr Burnand was not referred to a speech and language specialist as he should have been.
Mr Cox added: “Had that happened, I think the [speech and language] assessment would have taken place before November 18.
“I think it is also highly likely that direction would have been given for Mr Burnand’s food to be blended or pureed, and this choking incident would therefore not have happened.”
Returning a narrative conclusion, Mr Cox said: “Mr Burnand died after choking on his food.
“Professional care that would have prevented the choking incident was not given. His underlying Alzheimer’s dementia was a contributory factor.”
The Herald reported last week how Arcot House is now under new ownership.
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