A care home resident who died with a slice of carrot lodged in his throat may have lived were it not for an "inadequately prepared" meal, a coroner has ruled.

Peter Seaby, who had Down Syndrome, died while he was a resident of Oaks and Woodcroft care home in Mattishall after falling ill following his lunch.

He was admitted to hospital but died of aspiration pneumonia. He was 63 years old.

During an earlier inquest into his death held in 2021, a jury concluded that he had died of natural causes, sparking a judicial review from his siblings, Mick and Karen.

That lead to this week's second inquest, which was held without a jury and left senior coroner Jacqueline Lake to make a ruling instead.

Eastern Daily Press: Norfolk coroner Jacqueline Lake. PHOTO BY SIMON FINLAY

Giving a narrative conclusion, she criticised the home for an "inadequate" approach to Mr Seaby's care.

Following a review with a speech and language therapist, he had been put on a plan requiring him to eat only soft, mashed or puréed foods.

He was also required to receive one-to-one supervision throughout meal times.

However, on the day before his death - May 21, 2018 - he was given shepherd's pie and vegetables for his lunch and was not supervised.

During the meal, he began to cough, brought up food then continued to eat.

But that afternoon his condition deteriorated and he had to be admitted to hospital in the evening.

Mrs Lake said: "My conclusion is that Peter died of aspiration pneumonia and inadequate preparation of his lunchtime meal and inadequate supervision of his meal likely contributed to his death.

"I am concerned that five years after his death that I have heard evidence from witnesses that the care home still has an 'informal approach' to supervision."

She added that the home was wrong not to conduct an internal investigation into Mr Seaby's death.

A spokesperson for the home said: “We would like to reiterate our sincerest condolences to Mr Seaby’s family and friends.

"We have listened closely to the Coroner and will carefully study her comments to see if there is further learning. 

"We have already improved and enhanced the checks to ensure meals are prepared in line with residents’ care plans, as well as improved supervision of residents at meal times, ensuring that carers are confident in following the care plans.

"This sad death happened in 2018 and during this intervening time, processes have consistently been improved and are robust and comprehensive.”