A beloved wife and mother was neglected by care home staff in Darlington when she choked to death, an inquest has concluded.  

Brenda Preston, 73, died on February 28 this year whilst a resident at Ventress Hall Care Home, on Darlington’s Trinity Road. In the wake of her death, Brenda’s family say they have been left “completely destroyed”.

Brenda, originally from Newcastle, had lived in the care home since 2001 when she contracted a bacterial meningitis infection that left her physically and cognitively disabled. For 13 years before her illness, Brenda had herself worked as a carer at Ventress Hall.

(Image: Family Handout)

She had extensive care needs, and following an incident in 2016, when Brenda choked whilst eating, the inquest heard that she was put on a “soft mash” diet to keep her safe.

But at dinnertime on February 25, a carer new to the home gave Brenda a ham sandwich, which was prohibited by her anti-choking measures.

She was unable to properly swallow her food, and was discovered by a nurse as her lips turned blue. Brenda died three days later at Darlington Memorial Hospital, from severe bronchial pneumonia and gastric aspiration.

At an inquest today (Friday, September 20), the coroner concluded that although her death was accidental, staff had neglected Brenda because they had relevant safety information, but did not apply it. 

Crook Coroners’ Court heard that the carer had failed to read her care plan before feeding her, had no knowledge of her special mashed diet, and did not stay to monitor her mealtime as was necessary.

(Image: Family Handout)

Employees at Ventress Hall, run by the Care UK company, admitted that many of them were operating under the “assumption” that all staff knew about Brenda’s needs, as she was a long-standing resident.

Diane Encinias, the home’s manager, said that changes had been made to prevent similar incidents in future, such as a new visual reminder on residents’ bedroom doors about their care plans; a training presentation for all staff on choking risks; and discussions of every patient’s needs at handover.

But Brenda’s husband David and daughter Leigh Anne told coroner Crispin Oliver that they believed “inadequate management” robbed them of their “precious” mother and wife.

Ms Encinias admitted that the carer who gave Brenda the sandwich did not have “sufficient information, support or guidance”.

When asked if a “collective failure” had been made with Brenda’s care, Ms Encinias nodded, saying: “Mistakes have been made.”

When questioned by the family’s barrister Andrew Scott, Ms Encinias said that a resident at Ventress Hall had choked to death “six or seven years ago” – but that circumstances differed, as the individual was not on a restricted diet plan.

The home manager told the coroner that she knew another care home resident at a Care UK home, in Surrey, died after choking on food prohibited by their care plan. The company were later fined £1.5 million for giving "unsafe and inappropriate" food.

But Ms Encinias added that she knew of the case through the media, and did not know of any changes made by the Care UK brand in the rest of their homes.

Heartbroken husband David said: “I had to sit in the hospital and watch my beloved Brenda die – I will never forgive or forget.

(Image: Family Handout)

“Brenda was my whole life – now all that there is left is a grave to sit beside. I feel so lonely, because we loved each other so much.

“When we were in Covid lockdown, I would stand at her window [at the home] and tell her I loved her.”

Special exceptions had to be made at the home to allow David in, as Brenda would refuse to eat without him present. 

Later, when Brenda’s body was at a funeral home, retired funeral director David chose a room of rest with a window so he could say goodnight and tell her he loved her even over the weekend.

Leigh Anne, a teacher at a school in Hartlepool, added: “Inadequate management killed my mam and destroyed my dad. Friends of the family have had to report him to doctors as a suicide risk - he has been completely broken by this.”

(Image: Family Handout)

Care UK’s Regional Director, Dianna Coy said: “We again offer our condolences to the family of Mrs Preston.

“We pride ourselves on offering kind, safe care to all residents in our homes such that whenever a safety incident occurs, we carry out a thorough investigation to identify any areas of learning within the home. 

“We have already implemented several improvements to avoid this happening again and will further reflect on the findings of the inquest.  This home is currently rated “good” by the Care Quality Commission.”