Terry Hearn, 54, was found unresponsive at Buckingham Lodge nursing home, in Carbrooke, on the evening of February 10 after staff failed to monitor him following the drink, contrary to his agreed care plan.

Mr Hearn, who was born in Bury St Edmunds, Suffolk, had been living with a “totally disabling” form of Huntington’s disease since his diagnosis in 2004.

Buckingham Lodge care home in Carbrooke (Image: Google Street View)

By September 2022, his condition had deteriorated significantly, and he required full nursing care and PEG (Percutaneous Endoscopic Gastrostomy) feeding - a procedure involving a tube inserted into the stomach to deliver nutrition.

Despite this, following assessment by the Speech and Language Therapy (SALT) team, Mr Hearn was permitted to consume small amounts of thickened fluids and food orally, purely for enjoyment and quality of life.

These were to be provided under strict supervision, and Norfolk Coroner's Court was told that thickened drinks could be given by care workers but only under direct observation, followed by 20 minutes of........

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