A great-grandad who was unable to swallow died after a hospital gave him a corned beef pasty, an inquest heard.
Normal Neal choked after being served the pasty with chips followed by ice cream by employees of ward 40 at University Hospital of North Tees, Stockton, Teesside.
The inquest at Teesside Coroner's Court heard how workers failed to read medical notes, the Teesside Gazette reports.
The notes said Mr Neal, who was treated with antibiotics and fluids, was "nil by mouth," meaning he should not be fed orally.
The medical notes later went missing and he was left without fluids for around five hours.
Mr Neal had been diagnosed with Alzheimer's dementia.
Clare Bailey, senior coroner for Teesside and Hartlepool, heard how staff failed to ask the on-call doctor for more fluids for him when he ran out and did not place their new documents with the existing ones when they were found.
Mr Neal's death followed an earlier incident where he choked on a rich tea biscuit at Park House Care home in Stockton and had to be rushed to hospital.
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Health care assistant Amy Lofthouse, who was working on the ward, told the court: "We hadn't had the handover to say he was nil by mouth so we assumed he was OK.
"We have had people come in with face masks with oxygen before and they have been OK to eat so we made the assumption."
In her statement, she said Mr Neal had only taken one bite of the pasty before he went red and he was trying to cough.
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Ms Lofthouse added: "It was a good size chunk of pasty that came out, probably the same size as a 10p piece. He wasn't meant to eat or drink anything but we hadn't been told that."
Lynne Alston, associate practitioner, said she saw the notes at the beginning of the shift and then they went missing.
Mr Neal's daughter Barbara Youhana asked her: "If the notes were there at the beginning did they not say they were nil by mouth?"
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Ms Alston replied: "I didn't look unfortunately, I was busy looking after another patient."
Mr Neal, who served as a rear gunner in the RAF during World War Two, died on July 23, 2017.
The inquest was told how North Tees and Hartlepool Hospitals NHS Foundation Trust, which runs the hospital, has made a number of changes to the way they work since the tragedy.
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Staff have been given additional training and now use an electronic system, with a back-up paper file, instead of paper notes so they cannot be lost.
Larger boards have also been brought in and staff have been told to write in a certain corner using a particular colour.
Darren Elliott, who owns the care home, pointed out that hospitals use coloured bands to show staff that patients have allergies and questioned whether a similar method could be brought in for patients who are nil by mouth.
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Senior coroner Ms Bailey said there were clearly issues in care and communication and missed opportunities in respect of ward 40.
She said: "My conclusion is that Norman died from natural causes contributed to by choking episodes on the 18th and 19th of July 2017."
Mr Neal's heartbroken daughters, Barbara Youhana, Susan Bell and Dianne Minto, released a statement.
They said: "The family were disappointed that despite evidence in his medical notes that the transfer checklist from one ward to another was clear, including the telephone handover, the staff on the ward did not follow this, leading to a mistake.
"It’s been four years that we as a family have been waiting for answers from the Trust.
"To see our much loved dad suffering in his hospital bed , was very sad and heart-breaking and we would not want this to happen to another family."
A spokesperson for the trust said: "North Tees and Hartlepool NHS Foundation Trust and its staff share condolences with Mr Neal’s family.
"We have been in contact with the family to respond to concerns they have raised with us and reviewed Mr Neal’s care, alongside his family’s concerns, which has helped to identify learning and introduce relevant changes.
"We recognise the coroner’s conclusion and will be making no further comment at this time."
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