A man who choked to death on a burger after a care worker took him to a pub was failed by those charged with looking after him, his family says.
Tony Wilkinson, 57 and from Barnsley, had a genetic condition known as Fragile X syndrome, which causes learning difficulties and intellectual disability.
He died in April 2018 after he began choking while eating a Bronx burger in a pub at Manchester Airport.
An inquest jury has now ruled his death "unlawful".
Mr Wilkinson's family said he was only supposed to be given mashed food and thickened drinks.
They claim support workers from Stars Social Support Limited – a private company that specialises in providing adult care – often provided him with unsuitable meals, including taking him for fish, chips and mushy peas in Cleethorpes the week before he died.
Sheffield Coroner's Court confirmed that a jury returned a verdict earlier this week that Mr Wilkinson was "unlawfully killed".
Stars had looked after him on behalf of Barnsley Council since 2014.
Mr Wilkinson was initially supported at a daycare centre, with staff visiting his shared accommodation, but, after a choking incident in February 2018, Stars staff were then required to provide 24-hour care and supervision, his family said.
They said he was unable to manage his own eating and drinking, and staff were warned he faced a serious risk of choking.
Mr Wilkinson’s sisters June Mcdonald and Linda Swallow said in a statement: “We wouldn’t trust them to look after a goldfish now.
“The untimely death of our brother was preventable and avoidable, and a jury has now found it to have been unlawful.”
The added that the incident in 2018 should have prompted management to ensure his care plans were followed, saying: “That clearly didn’t happen as he was then taken out twice, firstly given fish, chips and mushy peas, and then a burger which killed him.
"Had this company acted in the way it should have, our brother would still be with us today.”
They added: “All of this has greatly impacted our mental health and our brother deserved so much better.
“Hopefully lessons are learned from all involved.
“The word 'care' is used to describe services provided, but it is not accurate as true care is not what is given.
“That goes from local authorities selecting these companies and then washing their hands of responsibility when things go wrong, to the providers themselves.”
Hudgell Solicitors' Simon Wilson said the inquest highlighted “a shocking lack of organisation and communication” which led to “inconsistent and inappropriate care which endangered life”.
He added: “Some of the evidence presented at this inquest was truly shocking as it painted a picture of a complete lack of organisation and communication which led to no clarity or consistency to the care provided to Mr Wilkinson.
“The lack of clarity and consistency over his care ultimately proved life-costing.”
Stars Social Support, which has not commented, must now provide the coroner with details of measures being taken to address the concerns raised, Mr Wilson said.
The company is currently under review by the Care Quality Commission.
