A CARE home resident choked to death on his dinner, but staff were not to blame for briefly leaving him to eat on his own, an inquest found.

Cerebral palsy sufferer Mark Pullen, 51, choked on his fruit and yogurt dessert on April 3 this year - and though staff at Birchwood care home in Chesham reacted quickly to try to dislodge the food, their efforts were unsuccessful.

Mark, described as an enthusiastic eater, was able to feed himself but required supervision to stop him eating too quickly, an inquest heard on Tuesday.

At about 5pm three staff members were with him and two other residents in a lounge at the Fuller Close care home, the inquest at High Wycombe Law Courts heard.

Two care workers, Manuela Dodson and Zoe Darvell, said they were in a kitchen area of the lounge when they realised Mark was choking, though the inquest heard there is no wall separating the two areas so the residents were still fully visible.

Trainee care worker Mafanta Daniels said she was feeding another resident when the incident started.

Efforts to dislodge the food by hitting Mark on the back and performing the Heimlich Maneuver were unsuccessful, and though an ambulance was called and arrived about 15 minutes later, paramedics could not resuscitate him, the inquest heard.

Coroner Richard Hulett said: "For a few moments Mark was left to carry on with his dessert course on his own. He did feed himself, it was normal for him to feed himself, but he needed to be reminded to eat more slowly.

"Within a very short period of time this has happened to him. The attention of staff was prompt and summoning of help was almost instant. But he went from having his meal to choking and going blue in a very short period of time.

"I can’t see that even in a near perfect world that much more could have been done to put this right."

John Inker, service manager at Birchwood, said: "This is my first occasion in 20 years that I've experienced that...Usually staff have been able to dislodge any food."

He stressed there was no restriction of view from the kitchen area of the lounge room, adding: "In terms of Mark we probably wouldn’t have done anything differently."

Mark used a wheelchair and was born in Amersham, but had lived at Birchwood for six years. His Cerebral palsy was also found to have been a factor in his death. Mr Hulett recorded a verdict of misadventure.