Skip to content

Mattishall care home did not follow resident's care plan, inquest told

Family handout Peter SeabyFamily handout
Peter Seaby had been cared for by his sister for 10 years before moving to The Oaks and Woodcroft

A care home where a resident died with a slice of carrot stuck in his throat did not comply with his care plan, an inquest heard.

Peter Seaby, 63, lost consciousness after a meal at The Oaks and Woodcroft in Mattishall, Norfolk, in May 2018.

His care plan directed that he should receive strict one-to-one supervision at mealtimes and only soft, moist, mashed food to avoid choking.

But deputy manager Deborah Cuzner admitted this had not been followed.

An earlier inquest concluded that Mr Seaby, who had Down's Syndrome and difficulty swallowing, died of natural causes and that the carrot was not a factor.

However, his family won a judicial review against its findings, prompting another hearing.

Norfolk Coroner's Court heard from Ms Cuzner, who was appointed a month before Mr Seaby moved in.

The care home, near Dereham, did not have a manager at the time, the inquest heard.

She told the inquest she would normally be in the office and that team leaders ran the floor.

Senior coroner Jacqueline Lake asked her: "Do you accept carrot unmashed found in his throat doesn't comply with the care plan?"

"Yes," she replied.

Qays Najm/BBC The Oaks and Woodcroft care home exteriorQays Najm/BBC
The Oaks and Woodcroft care home raised the alarm when Mr Seaby began vomiting

Mr Seaby should also have been allowed a 10-minute gap between food and fluids, and supervised for 10 minutes after his last mouthful.

Ms Cuzner admitted to the coroner that instead, he had "less time to eat".

The inquest heard Mr Seaby was also given a snack of banana and yoghurt and a cup of tea, despite a banana not being a suitable food under his care plan.

Gemma Peloe, a team leader at the home, was asked by the family's solicitor whether she was concerned who had prepared and supervised his food.

She responded: "I probably did know, but I don't remember."

She said Mr Seaby was one of the "loveliest ones" at the home, adding that he was cheeky and made staff chuckle.

The inquest continues and is due to conclude on Friday.

presentational grey line

Find BBC News: East of England on Facebook, Instagram and Twitter. If you have a story suggestion email [email protected]