Disabled patient on 'mash diet' died after choking on sandwich given to her in Darlington care home

A disabled woman, who had trouble swallowing and was on a 'soft mash diet', died after choking in a Darlington care home in February after she was given a ham sandwich, an inquest has heard.

Seventy-three-year-old Brenda Preston had been a resident of the Ventress Hall Care Home.

In 2001, she contracted bacterial meningitis, which left her with a number of physical conditions and the mental capacity of a four year old.

As a result of her disabilities she had trouble swallowing and was on a 'soft mash diet.'

On 25 February 2024 she was given a ham sandwich by a member of staff and was left to eat it without supervision. She suffered a cardiac arrest, as a result of choking on the sandwich, and died 3 days later.

At an inquest today, the coroner ruled that although her death was accidental - neglect contributed to it.

Katie Cole has been speaking to Brenda's husband and daughter.

Mrs Peston's family had chosen the Ventress Hall Care Home because she had previously worked there as a carer.

Mrs Peston's husband David said: "Never in my bold days of life would I have believed that they could have done that.

"They didn’t do it intentionally, but they did it.

"It was all their fault because somebody didn’t read a piece of paper and somebody wasn’t instructed."

The inquest at Crook Coroners Court today (20 September) heard that Ventress Hall Care Home did not follow 73-year-old Brenda Preston's care plan, when they served her a ham sandwich.

Care home manager, Diane Encinias, who had also once worked with Mrs Peston when she was employed at the home said Mrs Preston's death had impacted her and her staff.

She was not working the day of the choking incident but she said the carer looking after Brenda, who had only recently started working at the care home, had undergone training and had a ‘buddy’ that was a more experienced member of staff to shadow.

He had previously worked as a carer at another of Care UK’s homes.

Mrs Encinias said he had been given "all the training and tools to do his job".

She added that care plans for residents are available for all staff to view and staff are expected to be familiar with them prior to working with a particular resident.

She also said diet logs and plans are situated in the kitchen areas for residents and within residents rooms there are food charts which carers complete when providing food or drink.

Mrs Encinias said the diet log did not specify Mrs Preston should not have bread and said the carer who served the meal had not been given the support and guidance to support him that day by colleagues and said she agreed with the coroner that mistakes had been made.

She said following Mrs Preston's death all staff had had specific training on the risks of choking.

She also said residents' care plans were now in their rooms.

It comes after Mrs Peston suffered another choking incident while at Ventress Hall in 2016. She was treated at an Intensive Therapy Unit, eventually pulled through and returned to the care home.

It was at this point her dietary needs were changed to include a soft mash diet and no bread.

Today Coroner Crispin Oliver said measures were in place to minimise choking and were known to staff on hand at the time of the choking incident this year, but said they were not applied at time of incident and it is doubtful the care worker who provided Mrs Preston with the meal was informed of them properly.

He ruled Mrs Preston's death was accidental contributed to by neglect.

Care UK which runs the care home has previously been fined more than £1.5 million in 2022 after an elderly resident choked to death in another one of its care homes in the south of the country.

A magistrates' court found that staff at Mill View care home in East Grinstead, gave unsafe and inappropriate food to a male resident the "entire time" he was in their care.

The 86-year-old male resident died after choking on a "large piece of meat" in 2018.

After the ruling in 2022 a spokesperson for Care UK said they "had implemented a number of improvements across our homes to ensure we learn from this experience and minimise the chances of it happening again."

Today, in relation to the death of Mrs Peston, Care UK’s Regional Director, Dianna Coy said: “We again offer our condolences to the family of Mrs Preston.

"We pride ourselves on offering kind, safe care to all residents in our homes such that whenever a safety incident occurs, we carry out a thorough investigation to identify any areas of learning within the home.

"We have already implemented several improvements to avoid this happening again and will further reflect on the findings of the inquest.

"This home is currently rated “good” by the Care Quality Commission.”

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