A care home resident whose care plan stated 'no bread' died after being given a jam doughnut, an inquest has heard. Christine Thomas, 59, who had mental and physical health problems, was a resident at Swn-yr-Wylan Home in Rhos-on-Sea when the incident occurred on 13 January.
Support care worker Paula Parry, an agency worker, told the Ruthin inquest that she broke the doughnut into small pieces and gave Miss Thomas three, all with jam on them, before she collapsed. Mrs Parry said she was not aware of the 'no bread' instruction and felt her attention should have been drawn to it. She added that her training had not covered dysphagia – difficulties with eating – and she did not believe there was anything wrong with giving her the doughnut pieces.
Mrs Parry wiped away tears as she described how, after going to fetch a serviette, she saw Miss Thomas 'looked grey' and her lips were blueish. She did not appear to be choking, but her eyes were rolling, and Mrs Parry thought she was having a heart attack. Staff carried out CPR and paramedics managed to restart her heart. Miss Thomas was taken to Glan Clwyd Hospital but died on 4 February.
Paramedic Richard Roberts said he removed 'a small particle of food' from Miss Thomas's airway. Lynne Forbes, manager of the home, which is part of the Coed Du Hall group, said the first she knew of the doughnut being given was the day after the incident when Miss Thomas was in intensive care. Asked whether giving Miss Thomas even a small piece of doughnut complied with her care plan, Mrs Forbes said the plan did not refer specifically to doughnuts, adding that the dessert was 'more of a cake with jam'.
Asked what lessons had been learned, Mrs Forbes said training had been improved and more attention was being paid to care plans. The part-heard inquest has been adjourned to a date yet to be fixed, with the coroner stating she needed to consider whether to issue a Prevention of Future Deaths notice.
