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The choking death of a dementia patient revealed 'systemic' issues with supervision and meal delivery at a Sydney nursing home, a coroner has found.
Terrence Brinkley, 59, died on October 23, 2007, when a five by seven-centimetre piece of roast beef became lodged in his airway at Stanmore Nursing Home.
An autopsy found other pieces of unchewed meat and carrots in his stomach.
Mr Brinkley was known to gobble his food and often resisted nursing home staff requests to slow down and chew his meals properly, the inquest at Glebe Coroner's Court heard.
He also frequently stole food from the plates of other residents and was sometimes aggressive and would hit staff.
The inquest heard he was at high risk of choking because of his behavioural problems.
In delivering his findings on Tuesday, Coroner Hugh Dillon described the death as a tragedy but was satisfied with changes the home had implemented since the death.
'As a matter of fairness I can not be critical of staff or anyone including management,' he said.
Earlier in the day, the inquest heard Mr Brinkley's care plan stipulated his meals be pre-cut into bite-size pieces and he had to be supervised in the dining room.
It heard supervision meant that staff were to 'keep an eye on Mr Brinkley', not one-on-one supervision.
The role of cutting patients' food was the responsibility of nursing assistants who distributed meals.
Mata Manu, the staff member who gave Mr Brinkley his meal, had 19 other meals to distribute.
Asked whether she had cut up his meal, she said, 'I can't remember' but there were instructions to cut up his food written on the name tag on his plate.
Director of nursing Diana Brand told the inquest that management had put kitchen staff in charge of food cutting duties since Mr Brinkley's death.
This measure reduced the pressure on nursing staff distributing food and medicine in the dining room, she said.
Ms Brand said management had also introduced a modified texture diet to the nursing home - with regular, soft texture (pre-cut), minced/moist or smooth/puree options.
Staff training, including in CPR, had been increased and posters warning about choking risking were on display, she said.
During her evidence she reflected that Mr Brinkley was a 'compulsive' man.
'He hoarded food, hoarded everything ... clothes too,' Ms Brand said.
She said it wouldn't have been appropriate for Mr Brinkley to be hand-fed because he would not have cooperated.
The deputy director of nursing, Christian Sie, administered CPR on Mr Brinkley, who was turning blue, until paramedics arrived in the 2007 incident.
The inquest heard Mr Sie no longer worked at the home and that he had told investigating police officer Constable Joanna Jacques that working there was 'a bloody nightmare'.
'Complying with the (federal government's) accreditation took a large proportion of time ... spent a lot of time (dealing with) political issues that were not improving the lives of patients,' he told the inquest.
