There was no "coverup" in the death of an 86-year-old rest home dementia sufferer who choked on turkish delight delivered by his daughter, the Southland-Otago coroner says.

Coroner David Crerar found that Roy Middleton, who was a resident of Alexandra's Ranui Home, died a short time after being fed a large piece of turkish delight by a carer, who then left Mr Middleton on his own to aid another resident.

When the carer returned to find Mr Middleton slumped and not breathing, two other carers were called.

Despite the Heimlich manoeuvre being administered, Mr Middleton was never revived.

The manager of the home was then informed of the death, but not of the possibility of Mr Middleton having choked to death.

The manager briefly examined Mr Middleton, and decided on the information she had at the time not to call police, as would be standard in a choking death, as Mr Middleton was "very frail" and also had a history of heart problems and poor breathing, which she judged could have been the cause of death.

One hour after the death Mr Middleton's GP issued a death certificate listing a myocardial infarct as the cause of death - having not been informed of the possibility of choking either.

The chain of miscommunication that followed the death became clear during the coroner's investigation, but did not carry any sinister undertones, Mr Crerar said.

"Whilst I have no evidence that there was a coverup by those who considered choking to be a possible contributor to the death, the circumstances in which this information was not passed on to ... management at Ranui, and the doctor who completed the medical certificate as to the cause of death, is unfortunate."

Ranui manager Mavis Thornton had since acknowledged shortcomings in the way information relating to the death was communicated with the home.

"What happened, in effect, was that each of the staff directly involved with the incident ... relied on others ... to pass the ... information on to the registered nurse and ... management."

It was not until the choking issue was identified to management that the appropriate inquiries were undertaken, Mr Crerar said.

- © Fairfax NZ News