Published: 00:00, 27 May 2015
As coroner Ian Wade QC pointed out throughout the inquest into the death of care home resident Gail Cordingley, this hearing was "not a trial".
And true to his word, while questions were raised over her care at Frindsbury House in the time leading up to her death, the finger of blame never fell.
Beginning on Tuesday this week, the inquest at Archbishops' Palace, in Maidstone, heard that Miss Cordingley died after a piece of burger was caught in her airway during a meal at the care home in Wainscott on December 29, 2011.
Having suffered previous choking incidents before, Miss Cordingley, 54, was on a “soft-moist” diet at Frindsbury House and staff were instructed to cut up her food into manageable pieces and supervise her while eating.
However, a paramedic reported a triangular-shaped portion of meat about three inches long inside her trachea.
Carers battled to save her and she was rushed to hospital where she was placed on life support, but died six days later.
In summing up, Mr Wade said staff had adhered to the guidance given in Miss Cordingley's "care plan" - which itself was deemed to be appropriate for her needs - and had done all they could when she fell ill.
He noted that Miss Cordingley had a love of food, which was reflected in the care plan.
"Her likes and dislikes are joyously listed as 'she likes almost everything' and there are no dislikes noted," said Mr Wade.
"'When she eats and drinks she has to be supervised'- there's no further qualification to that, in particular it was not to 'supervise very closely'.
"It seems to me that this care plan reflected a compassionate and sensible attitude to Gail's needs. In particular there was no advice provided for Gail to be fed.
"It seems to me that this care plan reflected a compassionate and sensible attitude to Gail's needs..." - Coroner Ian Wade QC
"It may well have been that if I had concluded Gail's death could have been avoided then it might be that the advice given should have been of a different type - that she should have been fed rather than been allowed to eat herself. I don't think that would have been appropriate."
Addressing the specific events of December 29, 2011, he said: "the staff at Frindsbury House realised quickly and reacted quickly to what they perceived to be the event.
They immediately responded and tried to encourage Gail to expel the food, which appeared to them to be what she did.
"I asked certain questions about the methodology Frindsbury House had been taught to employ. I've concluded that what was done was appropriate."
Earlier the inquest heard that Miss Cordingley was one of 22 residents at the home, all with a range of learning and physical disabilities.
She was described as sociable and boisterous when in a good mood, but the exact nature of her condition – which afflicted her since the mid 1990s and meant she was confined to a wheelchair – was uncertain.
It was thought it could have been caused by a previous brain injury from an assault, or another choking incident which had resulted in her suffering a cardiac arrest and hypoxic brain injury, caused by a lack of oxygen.
Further conditions such as schizophrenia and epilepsy were possible contributory factors.
Staff at Frindsbury House said proper protocol had been followed up until and during the incident in December 2011, which manager Elaine Runeckles described as a “tragic accident”.
Barrister Andrew Bridgman, representing the family who have voiced concerns about her care, referred to evidence from paramedic Lisa Mason, who said she had found a piece of meat, which she described as “triangular in shape” and “about three inches long”.
“Would you regard that as a piece of meat that was cut into manageable pieces?” he asked.
Ms Runeckles replied: “It seems as though the piece of meat was quite long but it’s very difficult for me to comment.”
"She was on life support for nine days. She was in a deep coma. They tried everything. They said there was no helping her..." - Linda Cordingley
Mr Wade questioned the accuracy of that estimate, saying the paramedic had confessed she was uncertain and that other witnesses had described the piece of meat as the size of a 50p coin.
The inquest heard that the burger had been cut into quarters, rather than smaller pieces.
Carer Paul Harris had served Miss Cordingley and been supervising her just before she began choking.
“Gail asked me for a cheeseburger,” he said. “Someone said she could have a cheeseburger but it has to be cut up small. I checked with the kitchen staff and we cut it up into quarters.”
He advised her to take small bites, but left her for a matter of seconds to serve a pudding to another resident.
“When I turned around I looked at Gail and I didn’t think she looked right,” he said. “Gail’s cheeks were quite puffed up.
“She had gone red.”
Miss Cordingley had seemed to make a recovery, coughing up the contents of her mouth, and then asking for a drink, but a short while later she appeared to be unwell again.
Mr Harris said: “I realised that her colouring was changing. We decided to get her out of the dining room and into the hallway.”
Other members of staff then took control of the situation and called 999.
Miss Cordingley died in Medway Maritime Hospital from hypoxic brain injury and aspiration of food.
Her sister Linda Cordingley described how she had received a phone call shortly after Gail had choked.
"Sadly nature, in a very real way had taken it's course and had overwhelmed Gail. There was nothing that medical science, or love, or care could do..." - Coroner Ian Wade QC
“Gail was on her way to hospital and it was pretty serious,” she recalled in an emotional account. “We got there before Gail.”
“She was on life support for nine days. She was in a deep coma.
“They tried everything. They said there was no helping her.”
In summing up on Thursday, Mr Wade concluded: "I find that staff reacted quickly and did all they reasonably could do, but the food had lodged so deeply that it required long tweezers to extricate, the food, which couldn't be done in time.
"Sadly nature, in a very real way had taken it's course and had overwhelmed Gail.
"There was nothing that medical science, or love, or care could do."
He avoided verdicts of misadventure or accident, and instead chose to record a narrative verdict.
He said: "Gail Cordingley died at Medway Maritime Hospital on January 6 2012 from hypoxic brain injury as a consequence of aspirating food at Frindsbury House on December 29, 2011, during a supervised meal break. I record the medical cause of death as 1a) hypoxic brain injury, as a result of 1b) aspiration of food."
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