A NARRATIVE conclusion has been reached at the inquest of a Bradford woman with severe learning difficulties who died during a day trip.

Sarah Burnley, 47, died after eating a chilli con carne supermarket ready meal served to her on a minibus during a trip to Anglers Country Park, Wintersett, Wakefield.

Miss Burnley, of Creskeld Way, Allerton, was spoon-fed the meal from a flask by support worker Andrew Turasz, who was employed by Home Farm Trust (HFT), but she vomited, her lips turned blue and she lost conciousness.

She was then given CPR and chest compressions by care worker Sarah Malborough, who was also on the minibus, during the incident on March 18.

HFT was Miss Burnley's day centre provider and the Affinity Trust was her home service provider.

Giving a narrative conclusion, Bradford coroner Martin Fleming said there had been a breakdown in communication before the incident where HFT had not informed Affinity Trust where it was going on the trip.

Mr Fleming said: "I am fully satisfied that Mr Turasz and Mrs Malborough were fully acquainted with Sarah's needs, both equally assisted her and her specific eating habits.

"There is no evidence to suggest that the care given to Sarah was suboptimal in any way.

"Chilli con carne was a reasonable option for her to eat. Sarah's needs were properly identified.

He said the breakdown in communication between the two groups had now been improved.

"She suffered from severe learning disabilities which required 24-hour assistance, including with her food," he said, adding that immediate attempts were made to unblock Miss Burnley's airways.

Miss Burnley was treated by paramedics, who regained a pulse, and taken to Pinderfields General Hospital in Wakefield, where she died on March 20.

Her medical cause of death was a hypoxic brain injury followed by a cardiac arrest followed by a cardiac arrest secondary to aspiration food content.

A bronchoscopy showed Miss Burnley had food particles lodged in her airways and lungs which brought on a cardiac arrest.

Miss Burnley, who had no verbal communication, suffered from severe mental retardation, epilepsy since birth and impaired vision.

Reviews of Miss Burnley's diet and eating, including her risk of choking, on January 22 and February 12 this year, were considered of a low risk. This followed an occupational therapy review of her eating habits in 2011.

Her individual meal was reheated from frozen in a microwave and mashed up by a fork by Mr Turasz before they set out on the day trip.

Melanie Speake, operations manager at Affinity Trust, told the inquest yesterday that lessons had been learned around communication between HFT and the Affinity Trust.

She said: "I think we have all learned lessons from this incident.

"We now label all of the food in a service user's personal bag, including the ready meal packet.

"I am confident that the communication is robust between Affinity and HFT now.

"If Sarah had had any difficulty swallowing I would have made an immediate referral to the speech and language team (SALT), but there was no need to do that."