A man choked to death on a piece of sausage at a care home plagued with poor safety reports, an inquest has ruled.

Robert Lawson, of Folkestone, had been staying at Hawkinge House Nursing Home for a little over a year when the incident occurred.

Mr Lawson, who was known by his middle name of John to the carers, had dementia among other health issues and was on a strict soft food-only diet.

He was listed as a choking risk and needed to be monitored when in reach of food as he was known to have a tendency to take food that he wasn't supposed to eat, the inquest heard.

Carer Umila Rai said that the 65-year-old had eaten his specially prepared meal and gone back to his room on the afternoon of Saturday, September 8, 2018.

She said: "I was a floating carer, which meant that I had to attend to the patients who were in the lounge.

"I was reading to the three or four patients who were there from a newspaper, when I looked around and saw John in the kitchen area.

"I got up immediately and went over to him, and it became clear that he was choking..." Umila Rai, carer

"I noticed he had about half a sausage in his hand, and clearly had some in his mouth.

"I got up immediately and went over to him and it became clear that he was choking.

"I slapped him five times on the back and managed to get him into a chair and when I could not stop him choking I went to get the nurse."

The general nurse, Josin Jose, tried to aid Mr Lawson by slapping him on the back again and attempting chest thrusts but when this wasn't successful, he phoned an ambulance.

Ambulance crews attended but were unable to help and did not attempt resuscitation as the patient had a Do Not Resuscitate order.

The post mortem revealed a 38mm by 30mm piece of sausage lodged in his throat and his cause of death was given as choking.

Det Sgt Leanne Lawrence attended the scene and giving evidence said that it was clear that keeping an eye on Mr Lawson was an issue.

She said: "The way that the home was set out and because of how mobile he was, it was very hard to monitor him at all times.

"If he wanted to wander off, one couldn't keep an eye on him unless you followed him around at all times.

"The only issue was the fact that food was left out in that open kitchen area, it was a tragic accident."

"It is clear to me that staff acted in as swift a manner as possible..." Assistant Coroner Katherine Wood

Assistant Coroner Katherine Wood said that on top of her usual inquest duties, she also had to decide if issues drawn from the death represented a risk for future patients.

A routine CQC inspection carried out in 2017 found that the home, which cares for over 180 patients, had an 'unsatisfactory' approach to safety.

The inspectors mentioned that information concerning Mr Lawson's death "indicated potential concerns about the management of risk to people's health, safety and well-being.”

However, registered manager Julie Rhodes told the court that new training methods and the purchase of 'de-choking' devices meant that the latest CQC test showed an improvement.

The new report, which was published in April, shows that all ratings for the house now fall under 'requires improvement'.

Making her ruling, Miss Wood said: "With the evidence in front of me I can safely say that this was not a natural death but a tragic accident due to choking.

"I think that it is also noteworthy that Mr Lawrence had dementia, as I believe this may have indirectly contributed to his death in so far as his dietary needs and choking risk.

"It is clear to me that the staff acted in as swift a manner as possible in the circumstances. Maybe the food should not have been within reach but lessons seem to have been learned."

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