An elderly woman with dementia died after she was given the wrong food at a care home, an inquest has heard.
Ivy Arch, 87, was found dead after she had been given leftover sandwiches and left unsupervised in August 2012.
Police launched an investigation at Spring Lane Nursing Home in Nottinghamshire when a further 30 allegations of abuse were made.
The home was closed down shortly after the claims, which included sexual and physical abuse, were made.
The inquest at Nottingham Council House heard Mrs Arch, who was known as Betty, had been taken off solids and could only eat liquidised or mashed food.
She developed bronchitis after being given sandwiches and biscuits by staff.
A pathologist told the coroner undigested bread and vegetables had been found in her windpipe.
In giving evidence, workers from the home said it had been understaffed and they had been "run ragged".
Workers said they often had only four staff to tend up to 40 residents, some of whom had dementia and needed two people to care for them.
Manager Catherine Maltby said she had asked the owner for more staff but her requests "had been met with no positive response".
Owner Shirley Paul told the coroner she had no recollection of being asked for more staff and had not observed her employees struggling to cope.
Paul Balen, the solicitor for Mrs Arch's family, said they wanted to "make sure this never happened again".
The inquest continues and the coroner is expected to give her conclusion in April.