An inquest by HM coroner for Manchester South, Alison Mutch, has found that dementia patient Jane Olive Parker died due to neglect.

The inquest, which took four days to complete, found that Jane died in August 2016 after choking on a chicken nugget, a food she should not have been given by staff at the Fir Trees Care Home in Dukinfield, Tameside, due to her swallowing problems.

Alison Mutch reported that a Preventing Future Deaths (PFD) report would be issued as there was risk of other similar deaths occurring.

Jane was moved to Fir Trees in July 2016, which is run by care provider HC-One. She had a number of similar food-relating choking episodes, one of which in 2015 resulted in her being admitted to Tameside General Hospital.

In spite of a speech and language therapy team recommending that Jane should be kept on a stage 3 diet (food that is easily digested, for example soft or pureed food), Jane was given a dinner option of soup or chicken nuggets and chips on 24 August 2016, which would be served in her bedroom, resulting in her eating unsupervised.

After 40 minutes, she was found by care staff to be unresponsive, and was pronounced dead less than an hour later.

The coroner’s report stated that Jane was not given the appropriate food, and there was no escalation to the reporting manager. She was found to be on a care plan from her previous care home, and had not been reassessed in her time at Fir Trees. The coroner concluded that Jane “died from recognised complications from aspiration of food, contributed to by neglect.”

In a statement to Access Legal Solicitors, Jane’s son Richard, said: “The inquest gave us a lot of answers, but we still feel completely let down by HC-One. Staff should have known about her diet and should have been aware that her dementia meant that she didn’t have insight into the risks posed by choosing the meal that killed her.

“We still feel that our mother’s death could and should have been avoided.”

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