A disabled man choked to death on a marshmallow despite his sister scolding care home staff after finding an open packet of the sweets in his room.
Patrick Casey’s sister “flipped out” at staff at his carers at the London care home in the weeks before his death, an inquest heard.
Her 41-year-old brother was on a strict pureed diet when he choked on the soft sweet on April 5, 2019.
He was rushed to the emergency department at Barnet hospital but was unable to be saved, North London Coroner’s Court heard on Friday.
Birmingham-born Mr Casey had been a resident at the Priory Group-run care home Devon House in north London since 2014.
He used a wheelchair after suffering a serious brain injury when he was struck by a car in 2005.
Mr Casey’s sister Mary Casey told the hearing: “I want to know who played God with his life and who decided to give him marshmallows?
“He didn’t deserve to die in the way he did.
“It was so avoidable the way he died, it was just tragic.”
Referring to him by his nickname ‘Wacker’, she added: “Wacker lived his life to the fullest. He was one of the best people ever, such a caring, kind soul who never had a bad bone in his body.”
A medical cause of death was given as choking, aspiration (inhaling food into airways), and acquired brain injury, senior coroner Andrew Walker said.
Ms Casey told the inquest she had visited Mr Casey on Sunday March 17 – St Patrick’s Day – a tradition her brother “loved”.
“I went to his bedroom to get the shamrocks out and there was a bag of marshmallows in the room. I thought another patient must have left them.”
Ms Casey said she confronted a staff member about the sweets but was told: “No, they’re Wacker’s, he really enjoys them.”
She went on: “I said: ‘They’re very dangerous for Wacker.’ I flipped out, lost my cool, there was a lot of swear words.
“I told him: ‘Wacker can’t eat f*ing marshmallows, clearly he could fing choke.’
“I don’t understand – at what point did they decide to give him marshmallows when it clearly states on his care plans his food should be pureed?
“Why would they do that when we were so careful with him?”
Speech and language therapist Alexia Petrova told the hearing she recommended a fully blended diet after making a bedside assessment in January 2018.
She said: “He wouldn’t initiate chewing. Anything that had texture he was at a very high risk of aspiration or choking with it.
“I wouldn’t recommend marshmallows because they are a choking hazard. They have to be chewed. When it mixes with saliva it becomes extra sticky.”
Activity coordinator Eleanor Powell told the hearing she would buy marshmallows for Mr Casey to eat as it was “already a general culture when I arrived there”.
She said: “When I started he was having marshmallows and with my limited knowledge of thickened fluids and pureed meals I assumed that was something that would fall under the right kind of consistency for him to have.
“If I had any idea or indication he should not have been having them I would have gone out of my way to make sure he wasn’t having them.”
On April 4, she said she bought a packet of Mr Casey’s favourite Haribo marshmallows and left them unopened on his chest of drawers in a spot where the wheelchair-user could not reach for them.
Emotion came into Ms Powell’s voice as she gave her evidence over remote link.
A tearful Ms Casey moved to comfort her, telling her: “It wasn’t your fault so don’t feel guilty. You were close to Wacker and very good to him.
“Don’t cry – you were always very good to him.”
Ms Casey said she did not recall any formal meetings with staff about Mr Casey’s care or being involved in drafting care plans.
The inquest continues.