A woman with learning disabilities died after suffering a severe allergic reaction to soup provided by her carers.
An inquest was told that not all the support staff at Warwick Mews on the Weston estate where she lived were made aware of Deborah Mary Molloy’s lentil allergy and she fell seriously ill after eating soup containing a large amount of the pulse.
At an inquest into her death, Coroner Nicholas Rheinberg said Ms Molloy, who had Down’s Syndrome and did not understand her allergy, died as a result of ‘a catalogue of errors’ by the management. The inquest at Macclesfield Town Hall heard how Ms Molloy, 52, lived in a supported living home and was cared for by the Cheshire East Council’s care company Care4CE.
She had previously shown symptoms of a lentil allergy which was documented three times in her care notes. But it was not clearly displayed and some carers did not know about it.
Speaking at the inquest Mr Rheinberg said it’s unlikely any medical treatment could have saved her and did not apportion any blame on the care worker who gave her the soup.
Recording a verdict of death by misadventure, he told the inquest: “The organisation responsible for her care recognised the allergy but failed to implement a robust system to avoid problems. There were a catalogue of errors in the management context in respect of what had been identified as a reaction to lentils. Her care notes identified an allergy to lentils three times but were not prominently displayed. It would not do justice to her carers to describe the errors as neglect. I’ve not seen such caring carers. It was unfair the finger of blame was pointed at the carer who gave her the soup. She could not be expected to know about the problem with lentils.”
Ms Molloy was born with Down’s syndrome and abandoned as a baby. She was described by carers as a ‘loving soul’.
The hearing was told on the May 4, 2014, her carer gave her the choice of tomato or chicken soup for lunch at midday, but both contained lentils.
She ate the chicken soup and went to her room to listen to music, but was found seriously ill with an allergic reaction, anaphylaxis, at around 3pm. She was rushed to hospital and lost consciousness twice.
The inquest heard the reaction was more serious than originally diagnosed as she had a rare ongoing reaction called protracted anaphylaxis, caused by the amount of lentils she ate.
Ms Molloy died at around 8.30pm after suffering cardiac arrest, aspiration of gastric contents and anaphylactic reaction.
After the hearing, a spokesperson for the council said ‘lessons had been learned’. He said: “The Council wishes to express its regret in relation to the circumstances surrounding the death of Miss Molloy. This case did highlight lessons that need to be learned and the coroner accepted the Council’s evidence about the changes that have been made to systems since Miss Molloy’s death, so that any future cases of this nature can be avoided.”
