Neglect caused the death of a “caring and resourceful” father who choked on pieces of cauliflower served to him at a Highgate nursing home as he was helped to eat his meal.
Inner London North senior coroner Mary Hassell took the unusual step of naming neglect as the “standalone conclusion” of 80-year-old Cristofaro Priolo’s death after he choked on pieces of cauliflower fed to him at a Highgate nursing home.
The retired school caretaker had Alzheimer’s which meant was unable to feed himself and was at risk of choking. He moved to the Bupa-run care home in Hornsey Lane in 2020 after suffering a stroke.
The three-day inquest heard he suffered a cardiac arrest after choking on a meal of cauliflower cheese.
His care plan said he should be fed small, bite sized pieces of food and they had to be soft.
Paramedics who answered an urgent 999 call at Highgate Care Home used forceps to retrieve pieces of the vegetable from his mouth and throat.
London Ambulance Service clinical team manager Tom Waterworth said a large piece “was fully occluding the airway” and it was difficult to remove with specialist forceps.
“It was extremely firm, almost raw in its nature, it was very, very hard,” he said.
Ms Hassell said: “If you are looking after somebody who is in such a dependent position that you have to feed them, that they cannot do that for themselves, then absolutely basic that you must feed them food in a way that will not kill them. That is absolutely fundamental, absolutely basic. In this case, Mr Priolo was fed a large amount of cauliflower. It was so undercooked that it was nearly raw. “
She said she was struck by evidence that when paramedics used forceps to remove the food: “It wasn’t that the pressure of the forceps made the food disintegrate, it was that it snapped. That is a demonstration to me of exactly how hard that cauliflower was and how impossible it was for Mr Priolo to swallow that safely.
“My conclusion is that feeding him that cauliflower was a gross failure. It was a gross failure to provide adequate nourishment for someone in a dependent position who because of illness could not provide it for himself.”
She said she found “that represents neglect” and was her standalone determination.
Mr Priolo’s care plan stipulated he should have soft, bite-sized food. He had to be kept upright whilst he was fed, with no distractions, and staff had to ensure that he swallowed the food, to prevent him choking.
Care home manager Deeba Kazim told the inquest : “Sometimes he had to be reminded to swallow.”
She said Mr Priolo’s food should be mashed, around 1.5cm by 1.5cm maximum and he should be fed with a teaspoon to control the size of each bite.
Staff checked the care plan before feeding patients, she said. The catering staff were also aware of Mr Priolo’s needs, she explained.
Five pieces of cauliflower, varying from 2cm to 5cm, were retrieved from his mouth.
Ms Kazim said the food was not in keeping with his needs.
“I can’t explain how this can have happened,” she told the inquest.
It heard that instructions to the kitchen said Mr Priolo was on a “normal diet”, with soft food.
She said since his death “we are more rigorous and robust”.
The inquest heard a carer “used a fork and I checked it, it was soft but I still mashed it a bit more” and Mr Priolo was only fed small soft pieces of food and allowed to swallow before he was fed another small piece.
The alarm was sounded when his face became red.
Nurses rushed to the room, checked his blood pressure and performed the choking manoeuvre and used a suction machine to try and remove the food from his mouth. They also gave him oxygen.
Care home staff said Mr Priolo was still breathing when the paramedics arrived.
They were called by a senior nurse.
She said when she entered his room “he was showing signs of distress and discomfort and was having trouble breathing.”
She managed to dislodge several pieces of cauliflower.
She described how she started CPR after the paramedics arrived.
In a statement London Ambulance Service paramedic Andrew Donovan said nursing staff were doing CPR but “I took over as I was not satisfied by the position of techniques as they were ineffective.”
Coroner Mary Hassell asked about the paramedics’ assessment of her CPR.
“If they considered my chest compression was not right – I was very stressed as well and I think I did my best.”
His family paid tribute to the 80-year-old who “retained a kernel of cheerfulness throughout” even when Alzheimer’s robbed him of his independence and reduced his ability to communicate with them.
His wife Wendy and four children said he was a “devoted husband” and “caring and resourceful father” who “was always fixing things” and helped mend bikes for his children’s friends.
He was also a keen gardener and “would always have time for conversation with passers-by, more often than not there would be laughter too.
You could hear him from inside the house as he didn’t know how to whisper.”
They said they were “heartbroken that his life ended unexpectedly.”
Paramedics raised safeguarding concerns that the home “had not paid attention to his needs”, the inquest heard.
The police investigated but told the inquest that no further action is being taken.
Duncan Smith, Bupa’s managing director for 20 care homes in London and the south east said he tests food when he visits care homes and had never found vegetables that were not thoroughly cooked.
He said it “would appear” that the organisation “fell short”.
Since Mr Priolo’s death checks on audits have increased and care plans are becoming available electronically.
He said there were already regular checks and audits of residents’ care plans.
Other changes include looking at meal time procedures, advice that suction machines should only be used for liquids, and oxygen should only be used when prescribed. There are also regular reviews of training.
Duncan Smith, Bupa’s Regional Director for The Highgate care home said: “Our thoughts are with Mr Priolo’s family.
“Our carers work extremely hard to look after our residents. Since this very sad incident in 2020, we have enhanced checks to ensure meals are in line with our residents’ care plans. We have also implemented ongoing training and support for carers, to ensure that they are confident in the steps to take to prevent this happening again.
“We offer our sincere condolences to Mr Priolo’s family.”
This article was amended at 12:52 on Friday 13 May 2022 to add the comment from Duncan Smith, Bupa.