BURY coroner Simon Nelson is to write to the Commission for Social Care Inspection following the death of a mentally disabled man in a Prestwich care home.

He will seek more information on the commission's guidelines regarding staffing, and said lessons can be learned from the death of Jeffrey Marks.

The 52-year-old lived at the Meadhill Road care home run by Outreach, and was found dead on the floor of the dining room in April this year by support worker Miss Siphindile Zondi.

It was discovered that Mr Marks was mentally disabled at the age of three and had spent 30 years in care homes around the North West.

On the night that Mr Marks died, Miss Zondi had been alone caring for five residents at the home and had left Mr Marks and another resident downstairs, while she was caring for three more upstairs.

But on arriving back in the dining room, just a short time later, Miss Zondi found Mr Marks faced down between the radiator and the table, and called the emergency services.

An external examination after his death, at North Manchester General Hospital, showed that Mr Marks had died from choking after inhaling food and had a blockage of a hard green substance in his air passage. But because this was not a full post mortem and internal examination, the blockage was unable to be removed for further investigation.

The inquest, held in Bury on Wednesday, heard how Mr Marks was known to pick up food from the floor, and attempt to find food even after meal times.

The home's manager Leslie Smith told the inquest that the kitchen was always locked after meal times and residents would not have access to it.

She said: "Since Jeffrey's death I have thought about the situation, and I think that he might have found some food on the floor. Changes have come about since his death.

"The nightshift for staff now starts at 9pm instead of 7pm. We are also now in the process of trying to obtain more funding from social services to increase the night-time staff from one to two."

Mr Nelson recorded a verdict of death my misadventure, and said: "I intend to write to the Commission for Social Care Inspection following this inquest to ask them to comment on the guidelines surrounding the number of staff on call at Outreach care homes. This is not a criticism of the work of Outreach, but it is clear that lessons can be learned."