A MAN who choked to death in an Enfield care home was failed by health professionals, a review has ruled.

Enfield PCT failed to give 26-year-old Jesse Moores treatment for behavioural difficulties which made him put large objects – edible or inedible - in his mouth.

The Friern Barnet resident, who was autistic and had learning difficulties, was found dead on November 3, 2005, having choked on a ham sandwich he had snatched from another resident at the Chimes care home, in Enfield.

A Serious Case Review into his death found specialist advice for Mr Moores to have treatment for his compulsion to put objects in his mouth had not been implemented by the health trust.

And the report heaped criticism on Barnet Council, who were in charge of his care, and the firm running the now defunct care home.

Risks to him were downplayed by staff at the home and on the day of his death he was left in the hands of two unqualified staff members, one working with a false name and false certificates.

Mr Moores was found in his room unconscious with a a blockage in his throat the size of a golf ball.

Untrained staff did not try to resuscitate him, and the review judged that they may have thought he had already died.

They waited for the deputy manager – who was moonlighting in breach of contract working at a school – who phone for an ambulance, but Mr Moores was declared dead on arrival at Chase Farm Hospital.

The company running the home, Robinia Care, was fined £250,000 in 2009 and has since closed the home.

Discussing Barnet Council's role, the review found: “They were supposed to have a detailed contract with Robinia Care specifying the quality of care that they expected and the way they wanted this service to address Jesse’s particular needs and challenging behaviour.

“In fact there was no robust or enforceable contract in place and while this may not have contributed directly to Jesse’s death, it set the tone that led to an unaccountable service, operating in a cavalier way.”

Councillor Sachin Rajput, Barnet’s cabinet member with responsibility for Adult Social Care said: “It is clear that at the time of Jesse’s death there were clear failings in the centre in which Jesse was living and in how Barnet managed its relationship with that home.

“These were unacceptable and I am pleased that the report concludes that these failings have been addressed.

“But I am also very disappointed with the way the council failed to provide the support that Jesse’s family needed at the time when they were dealing with the tragic death of their son and brother.

“At times like this councils need to face up to their responsibilities rather retreat for fear of being sued over their liabilities.

“I know Mr Moores has been working with the council in recent months so we can make sure staff provide the proper support that families need in such times. I am very grateful that he has chosen to do so.”

Since Mr Moores' death a “complex case panel” has been established between Enfield PCT and Enfield Council social services to ensure people with medical and behavioural conditions are referred for specialist treatment.