A disabled man choked to death on a "fist-sized" lump of sausage roll that had been left out from a staff party at his care home, an inquest has heard.
Jimmy Billingsley, who had Down's Syndrome, was meant to be supervised while eating by workers at Naylorsfield care home in Liverpool.
The 55-year-old was on a speech and language therapist (SALT) plan due to a higher risk of choking, and was only served soft food cut into 2cm chunks.
But an inquest has now been told how, on December 18, 2021, he was seated with another disabled resident next to a bowl of cocktail sausages and sausage rolls left from a Christmas party the night before.
Jimmy with his mum Betty (Liverpool Echo)
The 55-year-old was at a high risk of choking (Liverpool Echo)A support worker said she was washing dishes in the kitchen when she noticed Jimmy get up and approach another member of staff, who had her back turned, reports the Liverpool Echo.
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Zoe Parr told the inquest: "She kept saying 'he's choking, he's choking', and started slapping Jimmy on the back.
"I went over to them and he was still on his feet. He was making a strange noise; he was gasping."
She slapped him on the back and attempted to perform the Heimlich manoeuvre.
But despite her efforts, she was unable to dislodge the mass of food in his throat, and he collapsed.
She said: "His breathing was laboured. He was going blue in his fingers and lips. The colour was draining from him."
Paramedics performed CPR at the scene and rushed Jimmy to hospital, where a CT scan showed he had suffered brain damage due to lack of oxygen.
His condition continued to deteriorate, and he died on Christmas Eve of a hypoxic brain injury due to a cardiac arrest caused by choking.
Vincent Jones, a medic who treated Jimmy, said the mass of food found in Jimmy's airway was "the most difficult blockage to clear of (his) career".
Jimmy, centre, with his many siblings (Liverpool Echo)Meanwhile, an EMT described it as "a large mashed lump of sausage roll" which was "fist-sized".
Ms Parr, an agency worker, told the inquest that staff were aware that Jimmy was at risk of choking and was not supposed to eat alone.
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But she added that she had not been given an induction when starting at the care home in November 2021, and had not been shown Jimmy's SALT plan, nor had she asked to see it.
She was told that Jimmy needed his food cut into "bite-sized chunks" by another staff member, the inquest heard, but admitted she did not do this and had served him a cheese roll cut into quarters instead.
Three-quarters were found on his plate, along with a handful of sausages.
Ms Parr said she had seen another member of staff take the sausages and sausage rolls out of the fridge.
But she added: "I don't know who put them in the bowl, or who put them on their plates. [Jimmy] could have helped himself from the bowl in the middle of the table."
She also said residents could have helped themselves to the food at any time, because they were not constantly supervised and the fridge was easily accessible.
When asked by the coroner, she said she did not fill in any incident report on the day that Jimmy choked, and made no personal notes of what happened.
Coroner Andre Rebello said: "It appears that Jimmy couldn't make the decision as to what was safe to eat, and that's why he had been supervised, and from your evidence it looks as though he wasn't.
"And not only had he got the barmcake cut into quarters rather than 2cm pieces, but he also had access to cocktail sausages and sausage rolls."
The inquest continues.
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