A woman who had previously tried to strangle herself choked to death on her lunch while in care.
Karen Bruen, 39, died in September 2009 after choking on a spoonful of sausage roll and beans, despite carers being told to avoid feeding her "pulses" and "flaky food".
Miss Bruen was under constant supervision at Pondside Avenue in Worcester Park after suffering brain and throat damage when previously attempting to take her own life.
After moving into the house in November 2008, an eating and drinking plan was drawn up to ensure Miss Bruen was fed safely.
Miss Bruen was not to be allowed bread, but in evidence at the inquest into her death at Croydon Coroners Court on Tuesday (November 8), carer Justina Cohen admitted she ate bread regularly.
The family of Miss Bruen had raised concerns about the use of care agency staff, of which Mrs Cohen was one, before her death on September 20 2009.
The inquest heard how after taking her medication at 12 pm on that day, Miss Bruen visited the toilet before sitting down to lunch.
Mrs Cohen told the inquest Miss Bruen had only had one spoonful of chopped up sausage roll and beans before she fell off her chair choking.
The coroner recorded a verdict of death by misadventure.
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