Pamela Thurston

“Mrs [name redacted] died at Norfolk and Norwich University Hospital on 7 July 2015 after choking on some toast she was given at Cedar Care Home in Yelverton, Norfolk two days earlier”

“Mrs [name redacted] ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours”

“The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen”

“On the morning of 5 July 2015, Mrs [name redacted] had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast”