An ex-international karate fighter died after choking on a burger in his care home, a coroner has heard.
Elan Adams, 69, was a much-loved karate instructor and had volunteered at Green Light Youth Club in Tower Hamlets before an illness forced him to move into Manor Farm Care Home in East Ham.
A coroner’s report into the former mechanic’s death found qualified staff failed to provide key information to the London Ambulance Service and raised concerns about how his care home had difficulty making emergency calls from residents’ bedrooms.
The report revealed Mr Adams was not a known risk of choking and he had no issues with swallowing his food.
He required staff provide him with his meals and he had been given a burger at around 6.30pm by care home staff on February 5.
But when staff came to collect his plate, around 30 minutes later, Mr Adams was found with the burger scattered over his lap and was not fully responsive.
A care assistant called for a nearby nurse, who attended and noticed Mr Adams had a concerningly low oxygen saturation level.
The report noted that at 7.14pm a call was made to the London Ambulance Service (LAS).
It explained a “poor history” was provided by the nurse, adding the sound quality of the call was also poor and “there was a lack of clarity around Mr Adams’ respiratory status”.
During the call, Mr Adams stopped breathing and the staff had to carry out chest compressions under the guidance of the LAS call handler.
Paramedics arrived at 7.41pm and took over resuscitation efforts. Mr Adams was taken to Newham University Hospital where emergency care continued.
Mr Adams passed away at the hospital shortly before 9pm that day.
Staff struggled to make emergency calls from residents’ bedrooms
Following an inquest, coroner Nadia Persaud ruled Mr Adams’ death was an accident but raised concerns about a number of issues.
Ms Persaud said the care home’s call to the LAS was “very poor quality” partly due to interference in the phone line connection.
The inquest heard staff had problems with the phone quality “most of the time” and continued to have difficulties when making emergency calls from residents’ bedrooms.
Nursing staff were also “concerningly unclear” when talking to the emergency controller.
In addition, the resident call bell at the care home had been faulty for an extended period, with the replacement which was provided being too quiet to be heard by staff at busy times.
‘He was a wonderful man’
Director at Green Light Youth Club, Theresa Moore, told the Standard: “Elan was just a godsend to the centre, he helped a lot of young people see their lives in a different way.
“He was a wonderful man.”
Meanwhile, Gerry Coulter, 70, who ran BIKO Karate with Mr Adams also told the Standard: “He was a fit guy, an international karate fighter when he was younger.
“Even as we were all getting old, we still ran a karate organisation.
“He just went downhill very fast, and we were all shocked when he died suddenly.”
Mr Coulter explained that Mr Adams had the bottom of one leg amputated after contracting cancer and having to go on dialysis.
Lloyd Williams, who met Mr Adams at the Renshin-Kai Karate Do and visited him at the Manor Farm Care Home described his friend as a “popular community figure”.
He told the Standard: “He knew everybody really in the community. He was a popular figure - most people knew him.
“He used to travel to Beckenham where there is a club that he was associated with.
“He took his students there for training once a week.”
Manor Farm Care Home confirmed that it had acted on all of the concerns raised by the coroner since the inquest into Mr Adams’ death.
Sarah Willits, Associate Operations Director at the care home, said: “We want to convey our sincere condolences to Elan's family after this terrible accident.”
She added: “We can confirm that the call bell was repaired and upgraded in early 2024.
“Our Telecoms provider has performed investigations to ensure phone lines are of consistent good quality throughout the home and recommendations will be implemented accordingly.
“We have also embarked on training for our team at the home, in particular to improve communication both internally and with emergency services.”
