A 30-year-old disabled woman, who suffered from swallowing problems, died after being fed yoghurt in a structured bean bag chair at a Sheffield day centre, an inquest heard.
Sheffield Coroners' Court was told how Cheryl Crawford, who was not able to communicate verbally, passed away at the Cambian Specialist Day Service Centre in Spa Lane, Woodhouse at 10.55am February 28 last year.
The wheelchair-bound 30-year-old was being fed a mid-morning snack of yoghurt in a 'p-pod' chair, a bean bag with structured postural support, when she suddenly fell fatally ill.
CSCSC Support Worker, Teresa Kelk, was feeding 'bubbly' Cheryl when she fell ill, and told the court she had fed Cheryl her mid-morning yoghurt snack while she was sat up-right in the p-pod chair 'many, many times' without any problems.
"She took the first mouthful fine. Cheryl's one of those who will close their mouth until she knows she's ready for the next one. I gave her the next one and the third," Theresa told the court in October. She added: "I was giving her the fourth and she went pale in colour. I shouted my colleague across to me because I knew something was wrong."
Ms Kelk said that they soon realised Cheryl was not breathing, and CPR was commenced as other members of staff at the centre contacted the emergency services. The Yorkshire Ambulance Service received the call at 9.55am, and arrived on the scene shortly afterwards.
Despite the best efforts of medics, Cheryl sadly passed away at the centre at 10.55am that morning, with her mother, Susan Crawford, and her sister, Hayley Crawford, present.
Dr Panagiota Kitsanta told the court in October that bits of yoghurt were found in her layrnx during a post-mortem examination.
During the conclusion of her inquest at Sheffield Coroners' Court today, Coroner, Louise Slater, said she accepted Dr Kitsanta's finding that Cheryl Crawford died of an acute airway bronchial obstruction. It was adjourned on October 20 last year, to allow for more evidence to be collected.
She recorded a verdict of narrative conclusion.
Records from Ms Crawford's GP confirmed she had a variety of complex medical conditions including cerebral palsy, epilepsy, severe learning difficulties as well as problems with swallowing, or dysphagia .
The court was told that Ms Crawford was hospitalised twice in February 2017 with aspirational pneumonia.
Susan Crawford told the court in October that when Cheryl was measured for a p-pod chair to be used at home in May of last year, Cheryl's physiotherapist, Christopher Smallshaw, told her that Cheryl must 'never be fed' in the chair.
This was reiterated by Hayley Crawford, who gave evidence during Friday's hearing, and said she also heard Mr Smallshaw make that statement to the group of people that were present during the fitting, including staff from the CSCSC such as Ms Kelk and the centre physiotherapist assigned to Cheryl, Caroline Hickson.
She said: "Because of Cheryl's dysphagia, he was saying she should not be fed in anything other than her wheelchair."
"This wasn't directed at any one person," added Hayley.
Mr Smallshaw said that he was of the opinion that Cheryl should not have been fed in the p-pod chair due to the fact she would not be as upright when sitting in it, but said he could not recall anything that happened, including conversations about feeding, during the day of the fitting.
His view on Cheryl being fed in the p-pod chair differs from that of Cheryl's CSCSC physiotherapist, Ms Hickson.
Ms Hickson told the court she believed it was 'perfectly acceptable' for Cheryl to be fed in the centre's p-pod chair providing the structured seat had been pushed back, forcing it into a more upright position, that pillows were used to support her back, and that she was sat upright, at an angle of at least 60 degrees.
Giving evidence this morning, Speech and Language Therapist, Melanie Long, said she had visited Cheryl, who was on a pureed diet at the time of her death, at CSCSC to assess her eating and drinking.
Ms Long said she was of the view that Cheryl should have been sat upright, as close as possible to an angle of 90 degrees.
She added: "I only observed Cheryl eating in her wheelchair, when she was in a suitable upright position. I was not made aware that she was being fed in anything else."
In her assessment, Ms Long, said Cheryl should be sat 'as upright as possible' when being fed, but did not state that she should not be fed in anything other than her wheelchair.
Both Ms Kelk and CSCSC manager, Helen Ullyett, told the court that it was never communicated to them in writing, or by any other method, that Cheryl should not be fed in the p-pod chair.
Ms Slater said that while she accepts that Helen and Susan Crawford had been told not to feed Cheryl in the p-pod chair, she did not believe this information had been communicated to CSCSC.
"I find that on the balance of probabilities this information had not been communicated to the day centre, or its staff," she said.