The first patient admitted to a Mental Health Rehabilitation Centre in Orford, Warrington died after choking on a sprout an inquest has heard.
The Court heard that the vegetable should have been cut up for the 50-year-old before being given to him.
An inquest on Friday, November 15th heard that Stephen Mawdsley’s care plan stated his food should have been cut up into pieces no larger than 1cm ‘due to ongoing problems with swallowing and choking’.
Mr Mawdsley was given an evening meal of chicken, potatoes, sprouts and broccoli, While his chicken and potatoes were cut up, the vegetables were not – and he choked on a large sprout and collapsed.
Having been rushed to Warrington Hospital’s intensive care unit, it was discovered that a lack of oxygen had caused a severe brain injury and his family agreed to turn off his life support machine.
Mr Mawdsley, described by his loved ones as a ‘really kind person and a good man’, died a week later on November 11th.
Mr Mawdsley had ‘ongoing problems with swallowing and choking.’
A lengthy police investigation followed, but no criminal charges were brought over his death.
Former staff members raised concerns about the ‘disorganised’ hospital during the inquest, with support workers highlighting confusion over where patients’ dietary plans were kept.
Giving her evidence, Laura Wills believed that practices should have seen food cut up in the kitchen rather than by the support workers who gave patients their meals.
She also expressed worries over the hospital’s cook only working until 3pm, at which point she would take on the role of a cleaner – leaving support workers to finish cooking pre-prepared evening meals.
Ms Wills said: “It was very disorganised, I don’t know why it was like that.
“The food should have been cut up in the kitchen and the cook should have been kept on until 5pm.”
Julie Peacey, the support worker who cut up the chicken and potatoes and gave Mr Mawdsley his meal, was unaware that he required all of his food to be cut into 1cm pieces.
She added: “I cut up the chicken and potatoes but not the broccoli and sprouts – I genuinely thought they were soft enough to eat.
“I hadn’t seen any food plan until two days after the incident.
“Nobody ever told me, I’d just seen other members of staff doing it – that’s how I knew what I needed to do.”
Heath Westerman, assistant coroner for Cheshire, recorded a conclusion of accidental death.
He said: “Stephen was assessed as being at a high risk of choking due to overload his mouth with food and eating too quickly.
“As a consequence, I believe that this was an incident which was an accident.
“I extend my sincere condolences to the family, and I hope that this can now bring some closure to this incident after such a long delay.”
A spokesman for Ash House, which is now known as Maple House Rehabilitation Centre, said the Warrington Guardian: “Following the tragic accident, as found by the coroner on Friday, many changes were implemented – including a review of the induction and training processes.
“Staff supervision was monitored, alongside other quality measures.
“The hospital was inspected by the Care Quality Commission in early 2018, and was rated as good in all areas – which further reinforced the changes that had already been implemented.”
Source: Warrington Guardian