A man who suffered from severe mental health problems had a heart attack after choking on a piece of toast while in hospital custody, an inquest heard.
Brian Davey, 67, had been an inpatient at a rehabilitation unit for people with mental health problems but at the time of his tragic death in October 2018, had been transferred to a different unit in hospital.
A jury inquest at Bradford Coroner's Court heard that the deceased, who died while in Dewsbury and District Hospital, Dewsbury, was estranged from his family.
In a statement one of his siblings, Josephine Lynch, told the court that she had not had anything to do with him for over 14 years, Yorkshire Live reports.
She said that his mental health problems had begun when he was in his 20s and had gotten worse as time went on.
The court heard that he had a history of problems with his swallowing and needed to be carefully observed when he was eating especially as he had a tendency to bolt his food down.
Typically, he would be seen to pack his mouth with too much food and try to eat it too quickly.
On 16 October 2018 he was given a half piece of buttered toast for his supper - as toast on its own was considered too much of a risk - and ate it under observation in the conservatory.
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Samaritans: Phone 116 123, 24 hours a day, or email jo@samaritans.org, in confidence
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Platform 1 men's community group: Support for issues including mental health problems and addiction recovery. Visit the website or call 01484 421143.
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PAPYRUS: A voluntary organisation supporting suicidal teens and young adults. Phone 0800 068 4141
Mind: A charity offering support and advice for people with mental health problems.
Students Against Depression: A website for students who are depressed, have low mood, or are suicidal. Click here to visit
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Later he left the lounge and walked into the dining room. He was noticed to be swaying and then collapsed.
Emergency resuscitation procedures were followed and he was transferred to Pinderfields Hospital in Wakefield where he died on October 18 after it became clear nothing more could be done for him.
A serious incident investigation report was produced which made some recommendations which assistant coroner Angela Brocklehurst welcomed saying it was reassuring that steps had been taken to improve procedures so that this sort of tragedy should not happen again.
The hearing continues tomorrow.
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