A woman with Alzheimer’s disease died minutes after choking while eating her pudding at a Surbiton care home, a coroner has ruled.

Joan Thornley, a retired box office administrator, was 78 when she died at Bourne House in Langley Avenue.

She began coughing after being fed a few spoonfuls of food at lunchtime on March 16, and died a few minutes afterwards.

Jevin Jose, the nurse who was feeding Mrs Thornley before she died, recounted her final minutes at West London Coroner’s Court on Tuesday.

He told her inquest that after she rejected a spoonful-and-a-half of her main course, he attempted to feed Mrs Thornley pudding – gateau mashed with milk.

He said: “I fed her one spoon. As soon as she swallowed the food she started to cough.

“I held her and I tapped on the bottom part of her back firmly. I kept tapping until I reached the stage that I felt she got her breath back. She did stop coughing.

“I left her in the same propped-up position.”

Mr Jose then went to feed another resident. He said: “I noticed that Joan was struggling to breathe. Her eyes seemed like bulge out.”

He and two colleagues took Mrs Thornley to her nearby room and put her in the recovery position. She died shortly afterwards.

Your Local Guardian:

Mrs Thornley, who was born in Kilburn in north-west London in October 1934, was admitted to Bourne House in 2005 following a diagnosis of Alzheimer’s.

The court heard she was known to struggle with dysphagia, meaning it was difficult for her to swallow food. Files showed she was at risk of “aspirating”, or breathing in, her food.

Medical examiner Dr Robert Chapman told the inquest he found a “significant quantity” of food in Mrs Thornley’s airways.

A spoon designed especially for people with difficulty swallowing was not used to feed Mrs Thornley, the court heard.

An internal review was conducted by the care home, which is run by LRH Homes.

Manager Paula Gratton said: “Nothing was found.” Kingston’s Adult Safeguarding Board was also alerted.

Her son Paul, 39, from Hampton Hill, said: “I am pleased we did have an inquest, but I wish there had been some recommendations.

"It is a tough thing.”

Mr Thornley praised court staff for their help. He added: “They have been great, very good. They were thorough and explained what was going on and why it was happening.”

Coroner Jeremy Chipperfield said: “I can only say I am very sorry for your loss. Thank you very much for attending.”

Conclusion: Accidental death