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Catalogue of errors led to allergy death.

A care home patient with Down’s Syndrome died from a severe, million-to-one, allergic reaction to lentils in her lunchtime soup, an inquest has heard.

Deborah Molloy, 52, had been a long-term resident at Warwick Mews residential home, Macclesfield, Cheshire, after being abandoned as a baby, Macclesfield Coroner's Court heard.

Many staff at the care home were aware Ms Molloy had a rare allergy to "legumes" such as lentils, soybeans and chickpeas but, on 4 May 2014, she was unknowingly offered tomato or chicken soup for lunch. Both contained lentils.

Miss Molloy ate the chicken soup and went to her room to listen to music. She was found suffering an allergic reaction at 3pm, rushed to hospital and lost consciousness.

Coroner, Nicholas Rheinberg, was told that she died at around 8.30pm after suffering a cardiac arrest due to the huge anaphylactic reaction.

He said it was unlikely that any medical treatment could have saved her and ruled that her learning difficulties meant she was unable to understand her own allergy. She had died as a result of "a catalogue of errors" by the care home's management.

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 was a catalogue of management errors in respect of what had been identified as a reaction to lentils. Her care notes identified an allergy to lentils three times but they 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 and it was unfair that the person who gave Deborah the soup was blamed."

Ms Molloy spent her entire life in care of the local authority and lived at Warwick Mews, a supported community of bungalows and flats for adults with learning disabilities, run by Care4CE, a Cheshire East Council-owned company which provides social care services.

After the hearing, a local authority spokesperson said: "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."

 

 

 

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