An inquest heard how Gordon Mordue, who was 82, died after choking on his dinner whilst at the Fountain Way, NHS Mental Health Unit, in Salisbury.
A Jury was told how Mr Mordue had moved to the facility in late 2019 due to concerns over his behaviour, and was eating Sausage and Mash when the incident happened in February last year.
They were also told how at the time Mr Modue’s death there was “no evidence of swallowing or eating issues at the time of the incident”.
Medical staff were immediately at the scene providing Mr Mordue with back blows and abdominal thrusts, but this did not help in clearing his airways.
Paramedics and police shortly arrived at the scene, providing food suction and CPR, but Mr Mordue was pronounced dead at around 5.50pm.
Doctor Matthew Flynn from Salisbury District Hospital said the choking was a “significant contributory factor” to Mr Mordue’s death, coupled with the health conditions he was already living with.
When asked by the Coroner if more could have been done to save Mr Mordue, Mr Jason Fisher (Ward manager for Fountain Way’s Amblescroft South ward) replied: “Not in that environment, the problem was recognised early,” adding that the treatment was “completed to the ability of staff”.
It was concluded by the coroner and eight jurors that the death was an accident, caused by “airway obstruction by food bolus”.