A much-loved grandad died after choking on chicken nuggets at a care home because staff failed to cut up his food and monitor his eating, an inquest has heard.

Dementia sufferer Bob Buckley was a known choke risk and required specialist care with meals during his stay at The Chase in Canterbury.

But after staff “neglected” their duties, the 75-year-old was seen turning “blue in the face” before suffocating, the coroners’ court was told.

Mr Buckley’s step-daughter, Lisa Parrott, described the home’s actions as “heartless”.

The hearing today at Oakwood House in Maidstone was told how Mr Buckley was known to ‘pouch’ his food – holding items in his mouth for long periods – and prone to eating quickly, a risk flagged by his wife.

Chase’s risk assessment stressed Mr Buckley required food to be cut into small pieces and staff to be close when he ate, although they did not need to sit next to him.

But on August 11, 2019, when Mr Buckley was found to be choking, staff tried dislodging food from his throat, repeatedly slapped his back and deployed a “thrusting” technique to help save him.

But despite two ambulance crews arriving in minutes, Mr Buckley’s heart stopped and, due to a do-not-resuscitate order, paramedics did not attempt to revive him.

Shortly after his death, Chase told the retired factory foreman’s family – and healthcare watchdog Care Quality Commission – that Mr Buckley had choked on cake.

But medics later discovered he had eaten whole chicken nuggets and half a baby carrot.

The court heard it was unknown whether the carrot had been left in his lap since lunch or ‘pouched’ and eaten later.

Coroner Ian Brownhill said: “The food was not cut into small pieces, and paramedics were surprised at the size of the food removed from Bob’s airway.”

The court was told a staff member referred to only as ‘Carer 1’ physically handed Mr Buckley the fatal plate of food.

Mr Brownhill continued: “Carer 1 handed Bob the plate of food at tea time. She also plated the food, which he ate.

“She previously said the plates were pre-prepared, but this does not accord with what she told police after his death.”

She was walking up and down in the lounge when Bob was choking...

The meal included chicken nuggets and chocolate cake.

The coroner said there was “absolutely no evidence” to support Chase’s claim Mr Buckley took nuggets from another resident’s plate.

Furthermore, ‘Carer 2’, was thought to have been responsible for monitoring Mr Buckley as he ate according to the manager.

But she was discovered to have left him – and other guests – unsupervised.

“She was walking up and down in the lounge when Bob was choking,” Mr Brownhill said:

“Carer 2 was aware they ought not to leave residents unsupervised but did so.”

Representatives for the care home argued at previous hearings: “The factorial matrix of Bob's death was so unclear that you could not conclude this was unlawful killing”.

Mr Brownhill said he had considered the conclusions of corporate manslaughter and gross negligence manslaughter.

But, while recognising Chase breached its duty of care, he could not conclude it met the requirements for either.

He recorded a narrative conclusion of neglect, adding: “Bob had been identified as a risk of choking despite the fact that those caring for Bob did not properly mitigate this risk.

“They did not cut up his food or monitor him closely enough.

“This led to his death.”

Ms Parrott told KentOnline: “My mum made it very clear on more than one occasion that Bob was a choking risk as he ate very quickly and tended to pouch food in his mouth. He had to have someone sit with him while eating.

“To hand over the care of your loved one to someone else is one of the hardest things you can do. The guilt of making that decision and what happened after will never leave mum.”

The family was forced to wait five years for the inquest to conclude due, in part, to criminal charges being lodged against a staff member.

Five years after Bob's death, no one from the home has ever contacted mum and apologised after that initial call to tell her what happened...

But in August 2022 the CPS dropped the charges.

Ms Parrott continued: “Mum was told he choked on a piece of birthday cake, but we later found out he had been given whole chicken nuggets while being unsupervised.

“We only found that out from reading the evidence much later. It was only two years later, after another visit from the CQC, that management left, and positive changes seem to have been made.

“It was shocking to find out the actions, or should I say inactions, that led up to Bob's death, but what made it worse was finding out what happened afterwards.

“Five years after Bob's death, no one from the home has ever contacted mum and apologised after that initial call to tell her what happened. How heartless is that?”

Just five days after Bob’s death, at a routine inspection, CQC rated the Chase care home as ‘inadequate’.

It was then put into special measures in 2021.

This moved up to ‘requires improvement’ following an inspection in April 2022.

A statement from the home said: “We acknowledge the coroner’s findings and would like to offer our sincere condolences and apologies to Mr Buckley’s family for their loss. Due to the ongoing investigations, which have now concluded, we have been unable to comment on this matter previously.

“Since Mr Buckley’s death, a new management team has been put in place. We have implemented a number of new policies and procedures, specifically in relation to the management of risks around diet and nutrition and all staff have received further training.

“A further inspection was carried out at the home by the CQC in May 2023 and the home was assessed to be ‘Good’ in ‘safe’ and ‘well-led’. We remain fully committed to maintaining this high standard of care to ensure the health, safety and wellbeing of our residents at all times in the future.”