A coroner has highlighted a catalogue of failings at a Nottinghamshire care home after a severely-disabled resident choked to death on a pickled onion.
The home said it had learned lessons from the death
An inquest heard that a voluntary worker put the onion in 27-year-old Martin Hardy's mouth, though his care list said he should only be fed liquid.
The worker was meant to help out only with social activities.
A verdict of accidental death was recorded. Mr Hardy died at the Leonard Cheshire Home in Retford in February.
Mr Hardy, from Clay Cross, Derbyshire, moved into the home last September when his family could no longer care for him.
In a wheelchair and with cerebral palsy, he relied on staff to feed him.
A volunteer care worker from Turkey, Sule Harman, said she put the onion in Mr Hardy's mouth for him to bite.
The psychology graduate was only meant to help out with social activities and had not read his care statement, which stated he should only be fed liquids or finely chopped food.
Coroner Nigel Chapman said the tragic death highlighted clear failings in staff training, supervision and emergency procedures at the home.
In the end, he said, it was down to the home's cook who tried and failed to carry out the Heimlich manoeuvre on the choking man.
Dr Chapman said if this had been done immediately by a member of staff trained in first aid, Mr Hardy would have been alive today.
After the hearing, Malcolm Bower-Brown, Cheshire Homes' assistant UK operations director, said they had learned some lessons.
He added: "We are committed to doing all we can to avoid anything like this happening in future."