A CARE home where a pensioner choked to death has been told to assess its patients’ health risks better.

David Austin, 67, choked to death on his breakfast at the Manor House nursing home in Merton, near Bicester, on September 15.

Staff knew that he was prone to eating his food too fast, and a care assistant warned him to slow down twice that morning.

But no note of this tendency had ever been made in his monthly care assessments, the last of which was on September 8.

At the inquest into his death at Oxford Coroners Court on December 19, deputy assistant coroner Nicholas Graham questioned how well the home had assessed Mr Austin’s health risks.

In a statement, care assistant Anil Gurung, who served Mr Austin his English breakfast that morning, said: “I observed David eating quickly as always and so I told him, as always, don’t rush.”

Minutes later, Mr Austin was choking on his food.

An ambulance was called immediately, but paramedics were unable to save him.

Addressing care home manager Keith Crowhurst at the inquest, Mr Graham said that Mr Gurung’s comments “would suggest to me that (Mr Austin’s eating too fast) was an issue.”

Mr Crowhurst responded: “Yes, to be honest I would have expected to see that reflected if it was an issue.”

Mr Graham asked if he knew why it wasn’t reflected in any of Mr Austin’s monthly care assessments since he moved to the home in March.

Mr Crowhurst replied: “I don’t know. Some people said he did eat too quickly but when he was asked he would slow down.”

Mr Austin’s brother Robert, who also attended the inquest, raised his own concerns about the level of care his brother had received.

In a statement which was read out, he said his brother’s health deteriorated at a “surprising rate” without any information being provided to relatives.

He said on one visit he saw his brother, after being helped to wash, led back to his room “half naked”.

He suggested that “management may be poor”.

Giving a narrative conclusion, Mr Graham ruled that Mr Austin had died from “food asphyxiation”.

But he said he was going to write a “prevention of future deaths report” for the care home’s managers, in which he would suggest that they should review how they assess patients’ health risks. He said: “I will issue a prevention of future deaths report and ask them to look at the adequacy of assessments for risks such as choking and if that should be included in care plans.”

A spokesman for the European Care Group, which manages Manor House, said: “Staff and residents were deeply saddened by Mr Austin’s death in September and our thoughts remain with his family.

“The coroner confirmed that there was no neglect in this case, but it is important to learn from any event like this.

“We have reviewed our care plans to more closely assess risk relating to this area.”