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Priory Devon House
  • Priory Devon House

    Disabled patient chokes on marshmallow despite warning from his sister

    A mentally disabled patient choked to death on a marshmallow, just weeks after his sister raised concerns when she found an open packet of the sweets in his bedroom, an inquest has heard.

    Patrick Casey was aged 41 when he choked in April 2019 and later died after being taken to Barnet Hospital’s emergency department, a Coroner’s Court has heard.

    Mr Casey had been a resident at the Priory Devon House in North London since 2014, after a serious brain injury he suffered after being struck by a car in 2005 left him in a wheelchair.

    Mr Casey’s sister, Mary Casey, approached care staff when she found an open packet of marshmallows on the month before he brother choked.

    She mentioned the open packet to a staff member during a visit, assuming it was for another patient, and she says she was told it was her brothers and ‘he really enjoys them’.

    Recalling the incident at the hearing, she said: “I said: ‘They’re very dangerous for Wacker (Mr Casey).’ I flipped out, lost my cool, there was a lot of swear words.

    “I don’t understand – at what point did they decide to give him marshmallows when it clearly states on his care plans his food should be pureed?

    “Why would they do that when we were so careful with him?”

    She told the hearing: “I want to know who played God with his life and who decided to give him marshmallows? He didn’t deserve to die in the way he did.

    “It was so avoidable the way he died, it was just tragic.”

    Referring to him by his nickname ‘Wacker’, she added: “Wacker lived his life to the fullest. He was one of the best people ever, such a caring, kind soul who never had a bad bone in his body.”

    A medical cause of death has been given as choking, aspiration (inhaling food into airways), and acquired brain injury, said senior coroner Andrew Walker.

    Speech and language therapist Alexia Petrova told the hearing she recommended a fully blended diet after making a bedside assessment in January 2018, due to his ‘high risk’ of choking.

    She said: “I wouldn’t recommend marshmallows because they are a choking hazard. They have to be chewed. When it mixes with saliva it becomes extra sticky.”

    Activity coordinator Eleanor Powell told the hearing she would buy marshmallows for Mr Casey to eat as it was “already a general culture when I arrived there”.

    She said: “When I started he was having marshmallows and with my limited knowledge of thickened fluids and pureed meals I assumed that was something that would fall under the right kind of consistency for him to have.

    “If I had any idea or indication he should not have been having them I would have gone out of my way to make sure he wasn’t having them.”

    Ms Casey said she did not recall any formal meetings with staff about Mr Casey’s care or being involved in drafting care plans.

    The inquest continues.

    Source: Times Series