AN elderly man choked to death in a West Somerset care home which was later given a ‘requires improvement’ rating by Care Quality Commission (CQC) inspectors.

Retired bus driver Don Beer was on a diet where his food had to be chopped up in tiny pieces no larger than the gap between the prongs of a standard fork because he had difficulty with swallowing.

But on November 22, 2022, he was found unresponsive in his room in Eastleigh Care Home, Periton Road, Minehead, and was declared dead just under two hours later.

Somerset Senior Coroner Samantha Marsh was told Mr Beer died of asphyxiation caused by a lump of food obstructing his larynx.

Mr Beer, aged 69, had been suffering Huntingdon’s disease and dementia while being cared for in the home, since re-named Minehead Nursing and Residential Care Home.

His condition affected, among other things, his ability to feed himself and to swallow, meaning staff had been keeping him on a ‘level five’ food and ‘level one’ fluid diet since November 1 that year.

‘Level five’ food diets have lumps of no larger than 4mm and should not be too sticky so they do not stick in the mouth or throat.

A ‘level one’ fluid is ‘slightly thick’ but still flows through a straw and is used for people who have difficulty swallowing thin liquids.

Mrs Marsh, conducting an inquest into Mr Beer’s death, said a post mortem showed the asphyxiation was caused by a ‘food bolus’, a semi-solid mass of food.

However, Mrs Marsh said: “Despite a detailed consideration of the evidence, it has not been possible to ascertain what this food substance was, when, or how, Don came to eat it.”

She concluded Mr Beer’s death was ‘accidental’ and caused by a combination of asphyxia, laryngeal obstruction (food), and Huntington’s disease and dementia.

In January, 2023, two months after Mr Beer’s death, the CQC inspected the home after receiving concerns about management of medicines and staff skills to provide good quality care to people with complex needs.

Despite an overall ‘requires improvement’ rating, the inspectors said the home’s level of safety was ‘good’.

They said: “People felt safe and with the staff who supported them.

“People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible and in their best interests.”

A spokesperson for Eastleigh Care Homes told the Free Press: “Don was a much-loved member of our community, and his passing 18 months ago was deeply upsetting for everybody who knew him.

“The coroner found that all the procedures around Don’s care were followed to the letter, and that no additional action could have been taken by our staff to prevent this tragic accident.

“The cause of death was recorded by the coroner as accidental.

“The wellbeing of all our residents is our highest priority.

“Our thoughts remain with Don’s loved ones, and we hope that the findings of the inquest will bring them some closure.”