Granddad dies choking on chicken nugget after staff fail to cut up his food

A grandfather who was a known choke risk at a care home died after choking on a chicken nugget - when staff failed to cut up his food as instructed.

Bob Buckley, 75, needed specialist care with meals during his stay at The Chase in Canterbury, Kent, but employees there "neglected" their duties at a meal time, an inquest heard. It led to Bob struggling with his dinner and he turned "blue in the face" before he suffocated.

The coroners’ court in Canterbury was told Bob was known to "pouch" his food – holding items in his mouth for long periods - and was also prone to eating quickly, a risk flagged by his wife. His risk assessment stressed Bob required food to be cut into small pieces and staff to be nearby when he ate.

But the food wasn't cut up, as instructed, and the much-loved grandfather died. Speaking after his inquest, the man's step-daughter, Lisa Parrott, described the home’s actions as “heartless”.

When Bob, who had dementia, was found choking by staff on August 11, 2019, they tried dislodging food from his throat, repeatedly slapped his back and deployed a “thrusting” technique to help save him.

But despite two ambulance crews arriving in minutes, Bob’s heart stopped and, due to a do-not-resuscitate order, paramedics did not attempt to revive him.

After his death medics discovered he had eaten whole chicken nuggets and half a baby carrot. The court heard it was unknown whether the carrot had been left in his lap since lunch or ‘pouched’ and eaten later.

Coroner Ian Brownhill said: “The food was not cut into small pieces, and paramedics were surprised at the size of the food removed from Bob’s airway.”

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The court was told a staff member referred to only as "Carer one" physically handed Mr Buckley the fatal plate of food. Mr Brownhill continued: “Carer one handed Bob the plate of food at tea time. She also plated the food, which he ate. She previously said the plates were pre-prepared, but this does not accord with what she told police after his death.”

The meal included chicken nuggets and chocolate cake. Furthermore, "Carer two", was thought to have been responsible for monitoring Mr Buckley as he ate according to the manager.

But she was discovered to have left him – and other guests – unsupervised. Mr Brownhill said: “She was walking up and down in the lounge when Bob was choking. Carer two was aware they ought not to leave residents unsupervised but did so.”

Representatives for the care home argued at previous hearings: “The factorial matrix of Bob's death was so unclear that you could not conclude this was unlawful killing”.

Mr Brownhill said while Chase breached its duty of care, he could not conclude the death met the requirements for corporate manslaughter and gross negligence manslaughter.

He recorded a narrative conclusion of neglect, adding: “Bob had been identified as a risk of choking despite the fact that those caring for Bob did not properly mitigate this risk. They did not cut up his food or monitor him closely enough. This led to his death.”

His step-daughter Lisa told KentOnline: “My mum made it very clear on more than one occasion that Bob was a choking risk as he ate very quickly and tended to pouch food in his mouth. He had to have someone sit with him while eating. To hand over the care of your loved one to someone else is one of the hardest things you can do. The guilt of making that decision and what happened after will never leave mum.”

The family was forced to wait five years for the inquest to conclude due, in part, to criminal charges being lodged against a staff member.

But in August 2022, the CPS dropped the charges. Lisa said her mother had initially been told Bob choked on birthday cake, and only learned he had been given whole chicken nuggets much later.

Lisa said: "It was only two years later, after another visit from [healthcare watchdog] Care Quality Commission, that management left, and positive changes seem to have been made. It was shocking to find out the actions, or should I say inactions, that led up to Bob's death, but what made it worse was finding out what happened afterwards.

“Five years after Bob's death, no one from the home has ever contacted mum and apologised after that initial call to tell her what happened. How heartless is that?”

Just five days after Bob’s death, at a routine inspection, CQC rated the Chase care home as "inadequate". It was then put into special measures in 2021. This moved up to "requires improvement" following an inspection in April 2022. A statement from the home said: “We acknowledge the coroner’s findings and would like to offer our sincere condolences and apologies to Mr Buckley’s family for their loss.

"Due to the ongoing investigations, which have now concluded, we have been unable to comment on this matter previously. Since Mr Buckley’s death, a new management team has been put in place.

"We have implemented a number of new policies and procedures, specifically in relation to the management of risks around diet and nutrition and all staff have received further training.

“A further inspection was carried out at the home by the CQC in May 2023 and the home was assessed to be ‘Good’ in ‘safe’ and ‘well-led’.

"We remain fully committed to maintaining this high standard of care to ensure the health, safety and wellbeing of our residents at all times in the future.”