A disabled man who choked to death on a plate of leftover sausage rolls was neglected by his care home, an inquest heard.
Jimmy Billingsley, who had Down's Syndrome, died on Christmas Eve 2021, six days after choking on a "fist-sized" mass of sausage rolls and cocktail sausages, which had been left over from a staff party and placed in front of him on a table at Naylorsfield care home, Belle Vale, where he lived.
The vulnerable 55-year-old was on a strict 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. But on December 18 he was seated alone with another disabled resident when an unknown member of staff served up the bowl of party food.
READ MORE: Disabled man choked on leftover sausage rolls from care home's staff party
He was taken to Whiston Hospital, where a CT scan revealed he had suffered brain damage due to lack of oxygen. He died of a hypoxic-ischaemic brain injury due to a cardiac arrest caused by choking on December 24.
Handing down an inquest conclusion of accidental death contributed to by neglect, coroner Andre Rebello said yesterday: "(Jimmy) was not adequately supervised in accordance with his care plan in eating which resulted in choking, proving fatal on December 24 2021."
Jimmy's sister Anne Dillon said: "Jimmy was really funny. He just wanted to stop everybody in the street and shake their hands and give them a thumbs up. He loved dancing, he loved singing. He just loved being with people. He loved any type of football – his favourite team being, obviously, Liverpool."
Jimmy had previously lived for 20 years at Acrefield House in Prenton before being moved to Rockfield on West Derby Road, Anfield. But in late 2021 social workers informed his family that the home had become too expensive, and he was briefly moved to Oakfield in Sefton Park before moving into Naylorsfield in November 2021.
His sister Pauline Myatt, 64, said: "When we went to the home, they told us straight away they could look after him and they had all the facilities. It looked really nice. It was a nice place. But they clearly could not look after him.
"When the incident happened, as next of kin I got a phonecall. They said Jimmy had choked – but that we didn't have to get in touch with the hospital, and they would get in touch with us. I don't think they wanted us to see what happened.
"On Christmas Eve, he died. I sat there all day watching him struggling to breathe after fighting to stay with him.
"All the time he lived in Prenton, he was having a good time, he was looked after. Then to go somewhere for just six weeks and lose him in that terrible way was heartbreaking, it was soul-destroying. We did all we did to look after him, and they purely neglected him, and there was nothing we could do."
Anne said: "We were all devastated. We just couldn't believe it. To think we put someone we loved and cared for him a home where we thought they were going to look after him so well."
She added that the family were not informed about the circumstances of Jimmy's death by the Alternative Futures Group, which oversees Naylorsfield, and only learned the truth nine months later.
Anne said: "All they told us was that he had a cheese barm and he must have choked on it. Nothing was mentioned about the sausage rolls until we read the paramedic's report nine months later. We were totally shocked then.
"Alternative Futures should have got in touch with us to tell us what happened, but they didn't. They let him down in the worst way possible."
Jimmy leaves behind two brothers, Tommy and Fred, and five sisters, Anne, Pauline, Elizabeth, Christine and Jacqueline. His mum, Betty Billingsley, sadly died in March 2023, having never learned the truth about her son's death.
Pauline said: "Jimmy was a character. He was very loving. He was our baby brother and we all spoilt him. He had a really good life in his own way; he was forever shaking people's hands and he could do it 20 times a day.
"For two years the incident has been hanging over us. We knew Alternative Futures were in the wrong. We knew they were neglectful. Now it's over with, I just feel really sad."
Alternative Futures Group said: "Jimmy, his family and friends have remained in our thoughts since his tragic passing in December 2021.
"At AFG, the safety and wellbeing of those who we care for was and remains our number one priority and like his family, we are devastated by Jimmy’s tragic death. We are assured by the coroner’s findings that there were robust systems and process in place, including supervision by two staff while Jimmy was eating. However, it would appear that staff did not have eyes on Jimmy at all times and this enabled him to access food, which was not in line with his SALT plan.
"The coroner noted the learning from this tragic event was shared with support staff. The coroner did not make any orders against Alternative Futures Group as part of his findings."
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