An Alexandra rest home resident who loved sweets choked to death on one of his favourites, Turkish Delight, the Alexandra Coroners Court has heard.
But it wasn't until the following day that the rest home manager was told there was a possibility the 86-year-old resident had choked on sweets - after an anonymous phone call was made to the coroner, the court heard.
Roy Middleton died in Ranui Rest Home and Hospital on January 9.
Otago Southland coroner David Crerar reserved his finding.
Johan Barker, a carer at the rest home, said Mr Middleton had no special diet or feeding requirements.
"He loved his lollies and he'd have Turkish Delight every night and maybe a couple of bits through the day."
She had given him a small piece of Turkish Delight about 3.35pm on January 9 and was then called away to another room.
"When I got back to Roy's room about five minutes later, I found Roy slumped in his chair and shaking, with saliva coming out of his mouth."
She rang the call bell and called for help. The registered nurse on duty was in another wing and her phone was being charged as the battery was flat. The nurse had a pager but there was a slight delay in calls reaching pagers.
Four other staff arrived to help.
Ms Barker did not think to check immediately if Mr Middleton was choking. It was the first sudden death she had encountered in the four years she had been a carer and she was "upset and confused".
Although she had not mentioned it straight away, there was no attempt to disguise she had given him a lolly.
Another carer, Lynne Melville, said she unsuccessfully attempted the Heimlich manoeuvre on Mr Middleton.
Counsel for Ranui, Sally McMillan said the home "acknowledges things could have been done better."
Ranui manager Mavis Thornton was on duty when Mr Middleton died and said none of the staff dealing with him told her there was a possibility he had choked on sweets.
The first she knew about that was when Dr Christine Williamson phoned her the following day to say the coroner had received an anonymous phone call that Mr Middleton had been given a sweet shortly before his death and there was a potential for him to have choked.
She had immediately launched an investigation and one of the outcomes was an improved communication system. Instead of a 20-second delay in the paging system there was now a 12-second delay. Registered nurses also carried pagers as well as phones.
"Very strong discussions" were held with the staff involved, but they were not "disciplined". Nurses and carers had since been given extra training in sudden death procedures and the need to ask questions.
There was no suggestion she had "waited for it to blow over", Mrs Thornton said.
Pathologist Alexander Dempster said the sweet was "big enough to obstruct the larynx and completely block the airway".
The sweet would have been sticky and even if the Heimlich manoeuvre was done immediately, it might not have dislodged it, he said.
He found the cause of death was choking due to "obstruction of the larynx by foreign material".
Dr Williamson said when he was called to Ranui to certify Mr Middleton's death, nothing was mentioned to her about the possibility he had choked. She therefore believed the likely cause of death was myocardial infarction as he had a history of ischaemic heart disease.
"His condition was such that he could pass away at any time. He was a vulnerable old man who had reached the end of his life, effectively."
CPR was unlikely to have helped him and giving oxygen would have been difficult if his larynx was blocked, she said.
Rachel Greer, who had been a caregiver at Ranui, said she left because of the circumstances surrounding Mr Middleton's death. She was concerned about the delays in Ranui's emergency call system and worried the incident might be "swept under the carpet".