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Coroner finds ‘neglect’ and issues ‘Preventing Future Deaths’ report in case concerning unnatural death in BUPA care home


Turan Hursit acted on behalf of the Priolo family in a 3-day inquest before Senior Coroner, Mary Hassell, sitting at Poplar Coroners’ Court.

Mr Cristofaro Priolo was an 80-year-old sufferer of Alzheimer’s dementia who resided at Highgate Care Home in London – a private care home managed by BUPA. He was fully dependent on carers and nurses for nutrition and hydration and required a ‘Type 6’ diet of soft and bite-sized foods. On 25th November 2020, Mr Priolo suffered a choking incident whilst being fed cauliflower by a carer. His airways became occluded and he very quickly began to struggle to breathe. Carers and nurses were unsuccessful in their emergency response to the incident and Mr Priolo was already in cardiac arrest by the time paramedics arrived at the scene. Using a laryngoscope, paramedics retrieved pieces of cauliflower which were between 2cm and 5cm in size and fully formed. Unfortunately, Mr Priolo could not be resuscitated and tragically died on the same day. Paramedics were so concerned by what they found at the scene that they made a safeguarding referral in which they identified potential “neglect” and “omissions” on the part of carers and nursing staff in respect of both the feeding process and the emergency response to the choking incident.

In a 3-day inquest at Poplar Coroners’ Court, Senior Coroner Mary Hassell investigated Mr Priolo’s feeding needs, the events of 25th November 2020, and BUPA’s response to the same. She heard evidence from carers, nurses, paramedics, and the Managing Director for BUPA Care Services, Mr Duncan Smith. Turan Hursit acted for the Priolo family, cross-examining 9 witnesses over the course of 3 days.

Following the conclusion of evidence and legal submissions, the Coroner recorded a short-form finding of ‘neglect’, indicating that there had been “gross failures” on the part of BUPA. She concluded that Mr Priolo had been fed “a large amount of cauliflower” which was “so undercooked that it was nearly raw” and that this was in direct contravention of Mr Priolo’s prescribed diet. Ms Hassell considered that there had been a “gross failure to provide adequate nourishment for someone in a dependent position who because of illness could not provide it for himself”. She indicated that despite it being rare for neglect to be used as a standalone conclusion, this was appropriate in the present case because Mr Priolo died in direct consequence of BUPA’s own acts.

Ms Hassell further indicated that she would shortly be issuing a ‘Preventing Future Deaths’ report in light of continued concerns about “several matters, the least of which is that witnesses were still not able to give an accurate description of treatment for choking in court after all this time”.

Turan Hursit acted as counsel for the Priolo family, instructed by Ash Menon of Hodge Jones & Allen Solicitors. The case was attended by the press and reported in the:


The Camden Citizen

The Ham & High

Wales Online.

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