THE DEATH of a man with dementia could not have been prevented, despite failings in staff communication, a jury concluded.

Colin John Jones, 56, had been staying at Hengoed Park near Oswestry before being transferred to the Redwoods Centre in Shrewsbury in November last year, where he choked on a sandwich in his room at around 6pm on January 11.

Summing up the evidence at Shirehall, Joanne Lees – assistant coroner for Shropshire and Telford & Wrekin - heard that a speech and language therapy referral had been made, but not actioned, after a previous choking incident on January 3.

Dr Ejaz Nazir, Mr Jones’ mental health consultant, told how he was not made aware of the January 3 choking incident.

But she told the jury that if they thought this was relevant to their conclusion, they must conclude that it did not contribute to the death of Mr Jones, whose usual address was in Bishop's Castle.  

A jury found unanimously that Mr Jones’ was an accident and that, despite staff communication failings, the death was not preventable.

The cause of death was given as hypoxic brain injury due to cardiac arrest and airway obstruction.

Early onset dementia and smoking were listed as contributing factor but not direct causes.