A disabled man on a strict eating plan choked to death on a "fist-sized" mass of sausage rolls left over from a care home staff party.
Jimmy Billingsley, who had Down's Syndrome, was placed on a speech and language therapist (SALT) plan due to high risk of choking, and was supposed to be served soft food cut into 2cm chunks and supervised as he ate by staff at Naylorsfield care home, Belle Vale, where he lived.
But on December 18 2021, the 55-year-old was seated alone with another disabled resident at a table with a bowl of cocktail sausages and sausage rolls left over from a staff Christmas party the night before.
READ MORE: People 'feared the worst' when car roof cut off after crash
At his inquest today, support worker Zoe Parr said she was washing dishes in the kitchen when she noticed Jimmy get up and approach another member of staff, who had her back turned.
She said: "She kept saying 'he's choking, he's choking', and started slapping Jimmy on the back. I went over to them and he was still on his feet. He was making a strange noise; he was gasping."
She slapped him on the back and attempted to perform the Heimlich manoeuvre, but was unable to dislodge the mass of food in his throat, and he collapsed.
She said: "His breathing was laboured. He was going blue in his fingers and lips. The colour was draining from him."
Paramedics performed CPR at the scene before taking Jimmy to Whiston Hospital, where a CT revealed he had suffered brain damage due to lack of oxygen. His condition continued to decline, and he died on Christmas Eve of a hypoxic brain injury due to a cardiac arrest caused by choking.
Paramedic Vincent Jones, who treated Jimmy, said the mass of food found in Jimmy's airway was "the most difficult blockage to clear of (his) career", while an EMT described it as "a large mashed lump of sausage roll" which was "fist-sized".
Ms Parr, an agency worker, told the inquest staff were aware that Jimmy was at risk of choking and was not supposed to eat alone. However, she said she had not been given an induction when starting at Naylorsfield in November 2021; she had not been shown Jimmy's SALT plan and had not asked to see it.
She said she was told Jimmy needed his food cut into "bite-sized chunks" by another staff member, but admitted she did not do this and had served the 55-year-old a cheese roll cut into quarters instead. Three quarters of this were found on his plate, along with a handful of sausages.
Coroner Andre Rebello said: "It appears that Jimmy couldn't make the decision as to what was safe to eat, and that's why he had been supervised, and from your evidence it looks as though he wasn't. And not only had he got the barmcake cut into quarters rather than 2cm pieces, but he also had access to cocktail sausages and sausage rolls."
Ms Parr said she had seen another member of staff take the sausages and sausage rolls out of the fridge, but added: "I don't know who put them in the bowl, or who put them on their plates. (Jimmy) could have helped himself from the bowl in the middle of the table."
She also said residents could have helped themselves to the food at any time, as they were not constantly supervised and the fridge was easily accessible.
When asked by the coroner if the home had completed an incident report, she replied: "No." She said she did not fill in any report that day, and made no personal notes of what happened.
The inquest continues.
READ NEXT
Baby rushed to intensive care after becoming unresponsive at home
Dad 'abandoned and forgotten' after spending eight months in hospital
Body of mum found by dog walker years after disappearance
Martin Lewis' 60 day warning over energy bills
John Lewis shoppers praise £24 dress that's a 'summer classic'