A care home resident whose care plan stated “no bread” died after being given a jam doughnut, an inquest has heard
Lynn Christine Thomas, 59, who had learning disabilities, started choking during lunch at Swn y Wylan care home in Rhos on Sea, Conwy county in January 2023.
An inquest into her death heard that staff had not been properly trained in knowing what foods were safe to give her.
Recording a conclusion of “misadventure”, the coroner said he was satisfied that procedures at the care home have since improved.
The hearing was told that Miss Thomas, who was known as Christine, had lived at Swn y Wylan for 25 years.
In 2022, she had been assessed by a specialist because she was having difficulty swallowing, and a care plan had been drawn up.
It included a specific instruction “no bread” but on 30 January 2023, an agency care worker gave her three small pieces of doughnut with jam on them.
Christine Thomas collapsed and was revived by paramedics, but died a few days later in hospital.
At an earlier inquest hearing in 2023, Lynne Forbes, manager of the home, which is owned by Coed Du Hall Ltd, was asked whether she accepted that giving Miss Thomas even a small piece of doughnut did not comply with her care plan.
She replied that the plan did not refer specifically to doughnuts.
“That is more of a cake with jam,” said Ms Forbes.
The inquest in Ruthin also heard from speech therapist Sian George, who said that trained staff would know what foods were high risk.
Mrs George had spent a considerable amount of time assessing Christine Thomas and drawing up a care plan for what food she could safely eat.
She told the inquest that she would “categorise a jam doughnut along with bread”.
“Many people eat bread so often, we don’t think about how it can form a solid mass in the mouth, which can be difficult to swallow if you have problems,” she added.
Coroner John Gittins said: “It is probable that carers were not properly conversant with the care plan, due to inadequate training.”
Esther Jones, from Coed Du Hall Ltd, said the training had since been improved and more attention was being paid to care plans, which the coroner said he accepted was the case.
Rebecca Richards, Christine Thomas’ niece, described her aunt as a loving and lively person who enjoyed music and dancing, and who was missed by all who knew her.
She said the care home had ignored her relatives, both while she was alive, and when they asked for answers after her death.
“I trusted them to look after my auntie,” she said.
“And that’s not happened.”
