Choking death at care home was accident
A CARE home resident choked to death on her lunch – despite being on a soft food diet.
Rita Maltby was put on the soft food diet in November 2012 after her GP had raised concerns that she had "started to choke on soft mashed food."
She died on February 26 at Aspen Lodge in Skegness shortly after being served carrots, meatballs and mashed potato.
Mrs Maltby, who suffered from Parkinson's disease and dementia, was sometimes allowed to eat unaided, and on this occasion was feeding herself.
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The soft food diet served by the home requires food to be broken up manually by a carer after it leaves the kitchen.
A coroner's inquest at Spilsby Registration Office heard that a mistake on a dietary requirements sheet, which had Mrs Maltby's meal down as chips, was corrected by a carer before her food was served.
The inquest also heard that the senior carer and sole trained nurse on duty at the time, Albena Marinova, believed Mrs Maltby was having a stroke – despite being told by two colleagues that she was choking.
She said: "I saw no evidence of her choking – her breathing was normal.
"The colour came back to her face, she looked confused, but she often looked confused.
"I thought she was ready for the next course."
Mrs Maltby, who suffered from frequent falls, was sat down in a chair away from her food before being taken to her room.
She died shortly after.
When asked by assistant coroner Richard Marshall about on-going training requirements as a nurse, Mrs Marinova said she had undertaken a three day training course in first aid which she believed was valid for two years.
When asked if she thought anything could have been done differently, she said: "There is nothing is else I could do differently.
"The moment I appeared there they said she had choked, but everybody in our place chokes."
Aspen Lodge care home is run by Four Seasons, an independent healthcare provider of nursing homes.
At the time of the incident, Four Seasons' safety policy required each carer to undertake a first aid e-learning course comprising of 20-40 questions.
The test, which is updated annually, had to be repeated until 100 per cent was achieved.
Edward Pleeth, representing Four Seasons, said a choking policy was introduced on June 18 this year as part of the CPR section in the e-learning programme.
He also emphasised that although the dietary requirements system previously in place was informal it, it was still effective but had now been 'formalised.'
He said: "At the time it was informal, everyone knew about it.
"Now it has been formalised, everyone knows it about it."
The post mortem gave the cause of death as 'aspiration of foreign material.'
In conclusion Coroner Marshall said: "This was a very unfortunate accident.
"Mrs Maltby has clearly choked on something, we do not know what.
"The conclusion I come to is simply one of accidental death."