Beloved father choked to death on cauliflower after Highgate Care Home 'neglect'

Inner London North senior coroner Mary Hassell took the unusual step of naming neglect as the “standalone conclusion” of Cristofaro Priolo’s death after he choked on pieces of cauliflower fed to him at Highgate Care Home.

The retired school caretaker had Alzheimer’s, which meant was unable to feed himself and was at risk of choking.

He moved to the Bupa-run home in Hornsey Lane in 2020 after suffering a stroke.

The three-day inquest heard he suffered a cardiac arrest after choking on a meal of cauliflower cheese.

His care plan said he should be fed small, soft, bite-sized pieces of food.

London Ambulance Service clinical team manager Tom Waterworth said when paramedics arrived, a large piece of food “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 it is 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 was struck by the paramedics' use of forceps to extract bits of food, saying: “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 be upright while being fed, with no distractions, and that staff had to ensure he swallowed the food, to prevent him choking.

Care home manager Deeba Kazim told the inquest Mr Priolo’s food should be mashed, around 1.5cm by 1.5cm maximum, and that he should be fed with a teaspoon.

“Sometimes he had to be reminded to swallow,” she said, adding that catering staff were aware of Mr Priolo’s needs.

Five pieces of cauliflower, from 2-5cm, were retrieved from his mouth.

“I can’t explain how this can have happened,” she said.

Mr Priolo was on a “normal diet”, with soft food.

She said since his death the home is “more rigorous and robust”.

A carer told the inquest they “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, performed the choking manoeuvre, used a suction machine to try to remove the food, and gave him oxygen.

A senior nurse who started CPR before the paramedics arrived said “he was showing signs of distress and discomfort and was having trouble breathing,” when she entered the room

She "did her best" to dislodge several pieces of cauliflower.

In a statement, London Ambulance Service paramedic Andrew Donovan said he took over from the nurse administering CPR as he "was not satisfied by the position of techniques as they were ineffective”.

Paying tribute, Mr Priolo's family said he “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 in a statement that 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 said 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 and audits have increased and care plans are becoming available electronically.

The home has looked at mealtime procedures, and introduced advice that suction machines should only be used for liquids and that oxygen should only be used when prescribed. There are regular reviews of training.