Care home staff battled to save choking woman

Dominique Fernee, 44, who was a resident at Burton Cottages in Bishops Lane, Robertsbridge, took the meat from the fridge behind the backs of staff on October 8, 2008.

The inquest heard Dominique had a history of bolting her food and staff never left her alone when she ate her meals.

She would also often pick food and inedible items off the floor, out of bins and dishwashers and try to eat them.

On the day of her death, Dominique was in part of the building known as Cottage Two with another resident.

Carer Robert Revell was upstairs preparing another resident for a trip out to Bexhill Gateway Club, an evening club for adults with learning disabilities.

A second member of staff, Anita Omoregba-Gates, was cooking chips in the Cottage Two kitchen.

Social care worker Lisa Chester-Linskey, who was working in Cottage One, came into the kitchen and asked Anita why the chips were taking so long to cook.

After an exchange of words, acting manager Laura Whitcombe took both women into her office, leaving Dominique and the other resident unattended for "no more than five or ten minutes".

Anita then left for Gateway with Robert and two residents whilst Lisa and Laura returned to Cottage Two.

As they entered the dining room, they spotted Dominique leaning over the bin.

A visibly upset Lisa told the inquest: "When I got there I realised she was putting the ham packet in the bin.

"When I looked at her face she was full to bursting.

"She was trying to swallow the food."

Dominique, who did not speak but was able to communicate, refused to spit the ham out and then the two women noticed her lips had turned blue.

They dialled 999 and Lisa tried the Heimlich manoeuvre twice before putting Dominique on the floor and trying to clear the ham from her mouth.

Dominique was rushed to the Conquest Hospital, but later died of brain damage caused by the choking.

Lisa had worked at Burton Cottages since May 2007, but chose not to return to the cottages after the death of Dominique.

Laura did not return to Burton Cottages for six months after the incident.

The inquest heard that there used to be locks on the kitchen cupboards and fridges, but these were removed some time in 2006.

Staff told the inquest the kitchen was rarely locked as denying access to it would have caused distress to residents, all of whom have some form of autism.

When asked if this would have posed a risk to residents, Laura said: "I think with all our service users, there's a risk with absolutely everything in all their lives."

She added: "If we tried to stop all of them they would never leave their homes or do anything.

"It's about us minimising the risk but allowing them to live their lives as they want to as much as we possibly can."

The inquest heard that annual reviews between 1998 and 2001 recognised Dominique picked up and ate inedible items and two "choking incidents" were recorded in 1999 and one in 2000.

There were no complete reviews available between 2001-2001, although a 2006 risk assessment showed Dominique was still trying to eat items from bins, pavements, dishwashers and carpets.

The incident was investigated by police and a file was sent to the Crown Prosecution Service.

However the CPS said no offence had been committed and said the incident was "a very tragic accident".

An inspection in June 2007 recognised Burton Cottages as a "good" home.

Another inspection after the death of Dominique found "some shortfalls", but nothing relating to the residents' death.

Since the incident, staffing levels at the home have been increased and more night staff are now in place.

The incident was also investigated by Social Services at East Sussex County Council who said there were "no failings of the duty of care" by the organisation.

Dominique's brother Paul Fernee, who was at her inquest, said he received regular reports about his sister from the Sussex Autistic Community Trust, who run the home, and was always happy with how Dominique had been cared for.

Coroner Alan Craze recorded a verdict of accidental death.