A MAN in his eighties died after accidentally choking on his dinner, an inquest heard.

Gordon Mordue, aged 82, had been living at Fountain Way in Salisbury at the time of the incident, sectioned under the Mental Health Act.

An inquest heard that Mr Mordue had been eating sausages and mash on February 3 last year, when he rushed to the communal area to cough up food.

He then started to choke.

Medical staff were immediately at the scene providing Mr Mordue with back blows and abdominal thrusts, but this did not help in clearing his airways.

Paramedics and police shortly arrived at the scene, providing food suction and CPR, but Mr Mordue was pronounced dead at around 5.50pm.

Senior coroner David Ridley told the hearing yesterday, December 6, that the records need to note whether the “untimely death” was directly caused by food obstruction, or if this was a contributing factor.

This inquest was held with a jury - a requirement as Mr Mordue had died in the care of the state, detained under the Mental Health Act.

Summoning a jury helps the coroner in identifying and rectifying any dangerous or inadequate services, in this case the handling of Mr Mordue at Amblescroft South ward at Fountain Way.

The inquest heard that the retired gardener had moved to the mental health facility on Wilton Road in November 2019, as he had experienced difficulties with his behaviour.

Diagnosed with dementia in 2017 and Alzheimer’s in 2019, this “affected his social situations” and “put others at risk” which resulted in the move, said Jason Fisher, ward manager for Fountain Way’s Amblescroft South ward.

Mr Mordue, who moved to the site from a residential home in Chippenham, had regular one-to-one sessions to monitor and support his behaviour.

Despite this, there was “no evidence of swallowing or eating issues at the time of the incident”, the inquest heard.

Doctor Matthew Flynn from Salisbury District Hospital said the choking was a “significant contributory factor” to Mr Mordue’s death, coupled with the health conditions he was already living with.

It was concluded by the coroner and eight jurors that the death was an accident, caused by “airway obstruction by food bolus”.

When asked if more could have been done to save Mr Mordue, Mr Fisher said: “Not in that environment, the problem was recognised early,” adding that the treatment was “completed to the ability of staff”.

Celia Moore, clinical lead at Avon and Wiltshire Mental Health Partnership NHS Trust, which manages Fountain Way, told the inquest the ways in which the trust is going forward following the incident.

While there is “no issue with practical care”, Ms Moore said that staff would be “more diligent in completing the rationales” for every patient, which in turn would mean “improvements in record keeping”.

A speech and language therapist is now based onsite, and cordless phones are required so calls can be made to emergency services while delivering effective CPR.

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