The hearing into William O’Connell’s death held at Harrogate Magistrates Court heard that some staff had been unable to travel to work at Alexander Court Care home on public transport.
The 85-bed care home was two staff short on Sunday July 6 when 76-year-old Mr O’Connell died, with just three carers and two nurses covering the workload usually met by seven or eight members of staff.
The inquest heard today that people in the care home dining room had stepped over Mr O’Connell’s body as paramedics tried desperately to resuscitate him.
Paramedic Paul Fairclough said: “When we arrived there was a gentleman on the floor unconscious. All the persons in there were still eating their meal at the time.
“The patients were still being fed and staff were stepping over trying to to collect meals.”
Coroner Mr Turnbull replied: “It must have been difficult to deal with people actually stepping over. Do you recall any of the patients being moved away?”
Mr Fairclough said: “Only when my colleague spoke to them.”
Another paramedic Gordon Pollard, who was also on scene, added: “There were a number of people sat at the table and some of them were wandering about as well.
“Eventually they were moved into another room.”
Mr Pollard told the court he was informed Mr O’Connell had been sitting on a nearby recliner chair in the dining room for about five minutes when he stopped breathing.
He added they measured no pulse and he was confirmed dead shortly after their arrival.
Carl Gray, who carried out the post mortem, said Mr O’Connell “had foodstuffs in his airways comprised of whole chips, bits of chicken and some vegetables”,
despite records stating he required a soft diet of food mashed up due to him not having teeth or dentures.
“There were large scale chunks of food which had gone through the larynx into the trachea”, he added.
“This was the worst case of trapped airways I’ve ever seen.”
Mr Turnbull said: “I’ve been told Mr O’Connell needed his food to be mashed up”, to which Dr Gray replied: “That does not comply with what I saw.
“There was whole food, certainly not mashed and quite big.”
Nurse Mirela Tibuleac earlier told the court it was her first shift as a qualified nurse on July 6 2014 when Mr O’Connell died.
She said: “We couldn’t supervise the residents properly and do the rest of the tasks.
“We tried to call for other staff but none came because how would we transport the staff?”
Ms Tibuleac had worked as a carer at the home since January 2013 after moving to the UK from Romania a few months earlier.
During an inspection in March 2014 the CQC found a catalogue of errors at the care home which charged between £550 and £725 per week.
Residents were at risk of malnutrition and the home failed to ensure people’s safety and welfare.
The home’s former manager Rebecca Monareng told the inquest that staffing problems stemmed from losing several key members of staff within a few weeks of one another in early 2014.
Ruling a narrative verdict, coroner Rob Turnbull said “nothing could have been done” to prevent Mr O’Connell’s death.
“The cause of death is obstruction of the airways by food, which was caused second hand by his Parkinson’s disease. I record a narrative verdict.
“It’s clear nothing could have been done to prevent Mr O’Connell’s death.”
Speaking to stepdaughter Ann Marie Gregory, he added: “May I pass on my condolences to you.”
Slamming the verdict after the inquest, Ms Gregory called it “shameful” and said she was “extremely disappointed and upset”.
Sobbing and shaking, she said: “Simple things could have saved his life, like proper staff on duty which you would expect from any normal care home.
“If so he would still be sitting here today watching Manchester United. Everyone keeps mentionning the Tour de France.
“If it was Christmas day you would have cover. These are vulnerable people who need to have people on stand by if people don’t turn up for work.
“I’m extremely disappointed with the verdict.
“He wasn’t being supervised. To hear there was nothing more they could have done for my father is a huge blow and will be a big blow to my daughter who didn’t come today.
“If that is the standard of care they give in Harrogate then it’s shameful to say the least.”
Ann-Marie’s friend Rose Stearn described Mr O’Connell as a “lovely man”.
“I used to look after him and he was never any trouble. He did have Parkinson’s later on his life but no one ever had any problems with him.
“He loved his jelly babies.”