A caring dad died after being fed "almost raw" cauliflower at a nursing home despite being on a soft food diet. Cristofaro Priolo was unable to feed himself and was supposed to be given food which was small and soft.
However he died after choking as he was being helped to eat a meal of cauliflower cheese. Now an inquest has ruled his death was a result of neglect.
Inner London North senior coroner Mary Hassell took the unusual step of naming neglect as the “standalone conclusion” of the 80-year-old's death. An inquest was told how the retired school caretaker had Alzheimer’s which meant he was unable to feed himself and was at risk of choking.
He moved to the Bupa-run care home in 2020 after suffering a stroke. The three day inquest heard he suffered a cardiac arrest after choking on the 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 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 they were 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.”
Mr Priolo's 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.
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