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Woman who choked on cake in Norwich care home died accidentally, inquest told

PUBLISHED: 06:30 23 April 2015

Eastgate House, Thorpe Road, where the Coroner's Court is situated in the ground floor. Picture: Denise Bradley

Eastgate House, Thorpe Road, where the Coroner's Court is situated in the ground floor. Picture: Denise Bradley

Archant 2012

A pensioner who choked to death on a piece of cake in a care home died accidentally, a jury inquest concluded.

Margaret Coe, 83, suffered from dysphagia - swallowing difficulties - and had been placed on a strict diet of pureed food, but was given a piece of cake by a carer.

She died at Heathcote Residential Home in Unthank Road, Norwich, on April 30 last year.

Jacqueline Lake, senior coroner for Norfolk, said in summing up that there had been no suggestion the cake was given to Miss Coe with malicious intent.

She added that the carer who gave her the cake was reportedly “upset”, and had not read the care notes properly - adding “I didn’t think. I gave her a small piece of cake.”

The 10-strong jury deliberated for 40 minutes before returning their unanimous conclusion.

Michael Stephenson, public protection manager for Norwich City Council, is leading an ongoing investigation into the incident.

He said that Miss Coe had been in the residents’ lounge during an evening when two night staff were on shift.

One carer, Patricia Dack, served drinks, cake and biscuits to residents in the lounge then left to help the second carer, who was assisting a resident upstairs.

When Ms Dack returned she saw that Miss Coe was choking and staff dialled 999, the inquest heard yesterday.

Miles Bateman, the first paramedic on scene, said in a written statement that he used suction equipment to try to clear Miss Coe’s airway.

But she was pronounced dead at the scene, paramedics notified police and at the request of police they handed a clinical waste bag containing matter cleared from Miss Coe’s larynx to officers at Earlham police station.

Detective Inspector Andy Guy, who was the investigating officer in the case, said that carer Ms Dack was initally arrested on suspicion of manslaughter and held in custody as a homicide probe began.

After a police investigation, the Crown Prosecution Service decided not to bring charges against any individual or company and the case was handed to the city council.

Ms Dack attended the inquest, but after legal arguments she did not take to the witness box.

Instead, she confirmed in a written statement that she was employed at the care home from 2009 to last year, and was on shift the night that Miss Coe died.

Susan Grieve, regional manager for Black Swan Care Group, which operates Heathcote Residential Home, said that Ms Dack had not completed a refresher course regarding the mental capacity of residents, that was due to be completed a month before the incident, but all her other training was up to date.

The inquest heard that the care home met all standards required by healthcare watchdog the Care Quality Commission, but Mr Stephenson said the city council had concerns.

These included concerns over staffing levels, and fears that aide memoire notices were not detailed enough, and the authority has issued an improvement notice against Black Swan Care Group.

Coroner Ms Lake did not order any reports, explaining that new shift information sheets in use at the home had allayed her concerns.

Speaking after the hearing, Tom Lyons, operational manager for Black Swan Care Group, said: “Heathcote very much regrets the death of Margaret Coe who was a much-loved resident.”

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