An intellectually disabled man with cerebral palsy choked to death on a sausage while eating dinner in an IHC care home.

The man’s food was meant to be cut into 1cm cubes and he should have been monitored and prompted to eat slowly.

Instead, he was given a whole sausage on the night he died in 2018 by a support worker who remained in the kitchen where she was unable to closely monitor the group of disabled residents as they ate.

Despite three of the group including the man being at risk of choking, a second carer went home early before dinner was served.

The Coroner found the man’s death was avoidable and referred it to the Health and Disability Commissioner who today found IDEA Services, a subsidiary of IHC, did not provide services with reasonable care and skill.

In her decision, Deputy Health and Disability Commissioner Rose Wall said IDEA Services and a support worker breached the Code of Health and Disability Services Consumers’ Rights in their care of the man.

The decision said the 59-year-old man, identified as Mr A, had been a resident of IDEA Services since July 2004.

His care plans stipulated his food must be cut into small pieces and he needed monitoring when eating because of his risk of choking.

The first support worker, Ms B, dished up the dinner and remained in the kitchen, which adjoined the dining room, while the residents ate.

The second carer, Ms C, had gone home early to do training that she couldn’t do at the house because the internet wasn’t working.

Mr A left the table during dinner and, after a few minutes, Ms B went to see where he had gone.

She found him unresponsive outside the bathroom at the other end of the house and immediately called 111.

She performed CPR but didn’t clear his airway and when paramedics arrived they removed a large piece of sausage from his throat. The man died in hospital two days later.

Ms B told the HDC the death had a profound impact on her and she no longer worked as a carer. Neither did Ms C and both said they were extremely remorseful.

IDEA Services’ internal investigation into Mr A’s death found there was a discrepancy between his two support plans in that one specified he also needed a support worker to sit at the dinner table with him and verbally prompt him to slow down and chew thoroughly before swallowing.

However, it denied there was a “culture of complacency” or that the discrepancy created a level of uncertainty or complacency.

It did not accept it had a lax approach to staff training and education and said the view by Ms B and Ms C that it was okay for Ms C to go home early was not appropriate.

Ms B said it would have been unusual to sit at the dining table while the residents were eating.

Deputy Health and Disability Commissioner Rose Wall recommended IDEA Services confirm there was an expectation that staff must have the express permission of their manager to leave a shift early. Photo / Supplied

But Wall disagreed. She found the death was preventable and the breaches of the Code involved “severe departures” in the standard of care provided.

Wall was critical that although IDEA Services had a system in place for managing risk, this did not translate into practice.

“It is disappointing that a lax practice had been allowed to develop at the house, with a culture of complacency in relation to the management of risk.”

She said the nature of the risks concerned meant there was simply no room for a lax approach or complacency.

“In my view, the clients receiving residential support at the facility were particularly vulnerable as they had a combination of intellectual and physical disabilities that placed them at added risk of harm, and they were reliant on others to intervene if they were experiencing difficulties.”

She said IDEA Services failed in its duty to manage the resident’s risks, keep him safe and provide an appropriate standard of care.

Wall noted that in August 2012 and April 2014, staff were sent a memo highlighting the significance of choking risks and the size of food pieces to be given to people with such risks, and in January 2016 a safety risk alert was issued to staff on the risks of cooking and serving whole sausages.

She said Ms B’s presence in the kitchen rather than the dining area during dinner was a “concerning failure” because it provided an opportunity to multitask.

“Ms B was not focused solely on the task at hand - being the direct supervision of residents while they were eating.”

She found IDEA Services and Ms B in breach of the Code.

While Wall made an adverse comment about Ms C for leaving her shift early, she considered there were mitigating factors.

“I am concerned by the disconnect between organisational expectations and the beliefs, attitudes and actions of the IDEA Services’ staff at the house.”

IDEA Services chief executive Ralph Jones expressed his sympathy at the death of the resident and said his thoughts remain with the man's family and friends. Photo / Supplied

IDEA Services chief executive Ralph Jones told the Herald in a statement the organisation was sorry for the death of a person in its services in 2018.

“We remain sorry and deeply saddened and want to assure his family and friends that we remember him and have learned from his death.”

He acknowledged the findings in the report and said IDEA had made changes since the death including increasing training on choking hazards, introducing new processes for ensuring first aid certificates are up to date, a new client management system that records people’s information, and a new health and safety structure.

Both support workers had provided written apologies to pass on to the man’s family.

Wall made several recommendations including that IDEA Services uses the case to support staff training as a reminder of the significance of a choking risk.

The HDC has referred the case to WorkSafe.

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.