The death of a mentally disabled Epsom man who suffered brain damage after choking on a piece of toast was accidental, an inquest found on Tuesday.

Andrew Cooper, 56, died on December 2, 2014 in Epsom Hospital after being found unresponsive four days earlier at the Shieling care home in Hook Road, Epsom.

The care home’s manager, Christine Ephraim, told Woking Coroner’s Court Mr Cooper had been eating breakfast before going to his bedroom with food still in his mouth on the morning of November 28.

She said he was found by a member of staff on the floor, with his back against the wall and his legs outstretched – and ‘very pale, creamy in colour’.

Paramedic Mark Hodsall said he found two chunks of bread – each about the size of a balled-up tissue paper – in Mr Cooper’s airway when resuscitating him.

He was rushed to Epsom Hospital, but after being told their son’s chances of a cerebral recovery were very small his parents, Reg and Audrey placed him on a Do Not Attempt CPR order.

Assistant coroner Dr Karen Henderson ruled that although Mr Cooper was known to over-fill his mouth with food due to behavioural problems associated with a learning disability and autism, events leading to his death were ‘unpredictable and unforeseen’.

Earlier speech and language therapist Lucy Wang said because of this, the Shieling care home were justified in not placing him on an all-liquid diet, which would have curtailed his quality of life.

She said: “Andrew’s difficulty with swallowing stemmed from behavioural – rather than physical – problems.

“He did have excessive dribbling when I assessed him and he had a tendency to walk around while eating, but physically his swallowing muscles were working well.”

Dr Henderson concluded no-one was at fault for Mr Henderson’s death.

She said: “Andrew died of hypoxic brain injury caused by a pulmonary event from which he was not going to recover.”

A secondary cause of death was listed as pneumonia caused by ‘choking on a bolus of food’.

A tearful Reg Cooper, of Ridgeway, Epsom, earlier described his son as a ‘very nice chap’ who – despite his mental and intellectual difficulties – very rarely lost his temper.

He said: “He had many people who liked him. He was very easy-going.

“He never lost his temper against another person. He was well-liked and very loved.

“Obviously I was very upset when he was diagnosed at three or four years old with a learning disability.”

The court also heard Mr Cooper was in and out of hospital with physical ailments in his final years, including thrombosis and slowly-healing foot wounds.

After the inquest, Reg and Audrey Cooper – who also lost a daughter 15 years ago – said hearing how his son died had been a painful experience.

Mr Cooper said: “It does open old wounds – not that they ever close really.

“I don’t believe in closure. It never gets easier.”