A piece of carrot found lodged in the throat of a man who should have been on a diet of soft, mashed food did not play a role in his death, an inquest has found.

The jury at an inquest into the death of Peter Seaby at the Norfolk and Norwich University Hospital on May 21, 2018, concluded he died of "natural causes".

Eastern Daily Press: Peter Seaby, who died aged 63 while a resident at The Oaks and Woodcroft Care Home, in Mattishall in May 2018.Peter Seaby, who died aged 63 while a resident at The Oaks and Woodcroft Care Home, in Mattishall in May 2018. (Image: Supplied by the Seaby family)

On August 23, the final day of the six-day hearing at Norfolk Coroners' Court, area coroner Yvonne Blake said the piece of carrot - which was 2cm in diameter - did not cause his death.

Mr Seaby, who had Down's syndrome, was living at the Oaks and Woodcroft Care Home in Mattishall when he died, aged 63. He was supposed to have been on diet of soft, moist and mashed food, so there were questions around how he could have got the piece of carrot.

But speaking to the jury, Ms Blake said: "I've been told by two experts that there was no evidence that the carrot contributed or caused Mr Seaby's death, so you must put the carrot aside. There is no evidence that the carrot was ever in his lungs.

Eastern Daily Press: Peter Seaby, who died aged 63 while a resident at The Oaks and Woodcroft Care Home, in Mattishall in May 2018.Peter Seaby, who died aged 63 while a resident at The Oaks and Woodcroft Care Home, in Mattishall in May 2018. (Image: Supplied by the Seaby family)

"There was some traces of some the fluid that was in his food in his lungs. There is some evidence that he aspirated something into his lungs, thought to be fluid. He didn't die of choking, he died of aspiration pneumonia."

As aspiration pneumonia - which was earlier identified as the main medical cause of death - counts as death "by natural causes" - the jury gave that as their conclusion.

Ms Blake gave her condolences to Mr Seaby's siblings, Mick and Karen, who were at the hearing.

Mick Seaby said ahead of the inquest: “It’s over three years since Peter passed and left a huge hole in our lives and our hearts."

Karen Seaby said of her brother, who she cared for before he was moved into the care home in November 2017: "Dad brought him up to be a gentleman, he opened doors for ladies, he was a lovely fella, it's a sad loss that he's gone."

Reaction to the conclusion

In a statement released after the inquest, Mr Seaby's family said they still wanted answers about his care plan "was not fully adhered to".

The statement said: "We will never forget our brother. It is because of him that we want to make sure something like this never happens to any other vulnerable person in our community again.

"Peter was not the first person with learning disabilities to die in a care home in Norfolk, but after today, we hope he will have been the last.

"We strongly believe had Peter continued to live at home with, and be cared for by, his family, he would still be with us today."

It said there were still questions around an earlier chocking incident, in April 2018.

The family said: "We need to see changes in the system."