SOUTH Cumbria's coroner has pressed for better first aid training for care workers after a 28-year-old disabled man choked to death on a piece of toast.

Paul Ashton from Grange-over-Sands was being looked after at a residential unit for adults with learning difficulties at Barrow when he started having breathing difficulties after breakfast on January 26.

Coroner Ian Smith concluded that better first aid training would not have rescued Mr Ashton but could save others.

Carer Dennis Head told an inquest that he had popped out to pour a bath for a fellow resident at the Stafford House unit after helping Mr Ashton to eat his cornflakes and toast.

Mr Ashton who had a mental age of a young child did tend to cram food in his mouth but on that day he finished eating without incident and told Mr Head he was done.

Yet when his carer walked back in the room moments later, he found Mr Ashton struggling for air.

"He looked quite distressed," said Mr Head, who broke down while recalling what happened.

"I got round the back of him, did the Heimlich manoeuvre. I had done it before when he choked on an apple. A little bit of cornflake came up.

"I thought that's got it' but it hadn't. I didn't know what to do. I couldn't leave him, I had to get help. I'm not a qualified nurse, the first aid I did on him I had seen on TV."

He radioed staff for back-up but the inquest heard that no one responded until he left Mr Ashton's flat and shouted for help. An ambulance was called and an ambulance technician took over from staff attempts to get Mr Ashton breathing.

But the technician realised specialist help was needed and called a paramedic who arrived two minutes later. Using eight-inch long forceps, the paramedic retrieved large bits of toast wedged deep in Mr Ashton's windpipe but it was too late to save him.

The inquest heard from Morecambe Bay Primary Care Trust service manager Philip Morgan that there were four staff on duty at the time what he called the "absolute safe minimum" - when it was considered that there should be five, or ideally six, in place.

Mr Ashton's father, district judge Gordon Ashton, said he believed lack of care may have been a contributory factor in his son's death.

"His propensity to choke was well known but in the end there were insufficient staff available to cope with his needs," he said.

The family had previously complained that staff shortages meant their son had not been allowed to leave the unit for walks with his mother.

Delivering a verdict of death by misadventure, Mr Smith said: "Lack of care or neglect is really a gross failure to provide assistance to someone in a dependent state I'm totally satisfied that what happened here did not go that far."

Mr Smith stressed that it was clear not all staff had current first aid training, although he acknowledged the trust was making efforts to improve that.

But he added that such training would not have saved Mr Ashton since the obstruction was so deep, it needed forceps to extract it.