AN ILL man who could only eat “soft, wet food” choked to death after carers served him cocktail sausages, mini Scotch eggs and sandwiches, an inquest heard.

Stephen Luckhurst, 51, who suffered mental health problems and epilepsy, should have been constantly supervised while eating.

Despite the fact he had choked three times in three years, he was served the food at his home in sheltered accommodation. It was later found that he had choked to death when a piece of sausage got stuck in his throat.

Yesterday, Nicola Hepple, Hampshire NHS Partnership Fareham and Gosport locality manager, admitted that although the food was cut into small pieces it had not been an appropriate choice.

She added that Mr Luckhurst may have been considered low risk as his previous choking incidents were recorded as seizures and monitoring more than one person could be a “constant juggling act”

and was not always possible.

Coroner David Horsley said the only reason he wasn’t making recommendations was that a series of measures had since been brought in to ensure the tragedy was not repeated.

He said: “Sadly it has taken Stephen’s death but lessons have been learnt.”

Support worker Carol Burke told the inquest in Portsmouth how she had served three residents and was supervising them on the day he died.

She said she had taken a plate to the kitchen and was tending to another resident when she noticed Mr Luckhurst, of Coldeast Way, Sarisbury Green, had gone quiet, was slumped forward and had a “shocked look” on his face.

She tried slapping him on the back, upward thrusts on his stomach and clearing his airwaves. They could not find a pulse and tried to resuscitate him until paramedics arrived. He was taken to Queen Alexandra Hospital in Cosham where he was pronounced dead on December 30 last year.

Since his death the court heard a series of changes had been brought in including a review of all service-users with eating problems, improved training and clearer guidelines.

Mr Horsley, who recorded a verdict of accidental death, said: “There was some confusion about what Stephen should be eating. Whether he should have been allowed to get sausages is doubtful. From what I have heard in the main he was looked after well.”