The family of a dearly-loved wife and mother, who choked to death on toast after going without food for almost 18 hours at a Norfolk care home, told an inquest they felt she had been failed.
The daughter of Pamela Thurston, who had Alzheimer's Disease, had dropped in to Cedar House Care Home in Yelverton, for a surprise visit. But she was greeted by the 'heart-breaking' sight of her mother lying on the floor.
An inquest heard the 78-year-old went unfed from about 5pm on July 4 to around 11am the next day.
Norfolk Coroner's Court heard Mrs Thurston was then made toast, which a fellow patient said she ate 'like a hamster'.
But her daughter Louise Hopes told the inquest when she arrived at midday, she saw ambulances outside the Church Road home.
She said: 'We had no idea the ambulances were there for my mum, or what was happening inside. The heart-breaking sight of my mum lying on the floor of the conservatory will stay with me for the rest of my life. This should never have happened.'
The inquest heard registered nurse Eileen Quigley attempted first aid and resuscitation.
She said: 'With us being short-staffed I said I would stay in the conservatory.
'Pamela never gave us concern so we would not sit and watch her.
'One of the residents shouted 'she's stuffed that in her mouth', so I ran over. I rang the alarm and nobody came for a few minutes, so I went and shouted for help.'
Mrs Thurston was taken to the Norfolk and Norwich University Hospital, but died two days later.
Husband John Thurston told the inquest: 'If the correct level of care had been in place, my wife's death could have been avoided. I handed over the care of my wife to Cedar House and they failed her.'
He said he had previously found prune stones in his wife's mouth after a meal and warned staff of the choke risk.
He said. 'There needs to be more training around dementia. Many people still don't really know what Alzheimer's is or comprehend the consequences.'
But Ruth Halls, home manager at Cedar House, told the inquest: 'There was no discussion about Pamela being at risk of choking. If there was she would have been referred to the GP and speech and language therapy team.'
DS Paul Claxton, from Norfolk police, said it was 'clear there were no criminal offences.'
Johanna Thompson, assistant coroner, concluded accidental death, but said: 'It remains of concern to me there needs to be in place an adequate system to ensure residents are provided adequate meals in a timely manner to prevent a risk of anything similar happening in the future,'
A spokesperson for Cedar House said the home would update its record keeping procedures around meals.
They added: 'We offer our deepest condolences to Mrs Thurston's family at this very difficult time. The health and wellbeing of each resident is our absolute priority.'
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