A care home company has been fined £640,000 after a resident choked on a piece of doughnut and died.
The 65-year-old woman was on a specialist diet of minced and moist food at Orchard Care Home in Tullibody, Clackmannanshire after a severe stroke and vascular dementia left her at risk of choking.
However on August 7 2019, she was given a piece of a jam doughnut from the tea trolley at the care home, which she then choked on.
Despite the efforts of care home staff and paramedics, the woman died.
At Falkirk Sheriff Court on Wednesday, HC-One Limited, who run the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974 and were fined £640,000.
After being assessed for a high risk of choking on December 2 2018, the resident was placed on a minced and moist diet.
Bread products such as doughnuts are not suitable for the modified diet as they cannot be mashed small enough.
However prior to her death, the resident had frequently been given sandwiches from the snack trolley, repeatedly putting her at risk.
While main meals at the home were prepared in the kitchen and labelled with each resident’s name, the snack trolley did not have information on modified diets or food suitability.
Staff in charge of the trolley did not have sufficient training on modified diets.
HC-One Limited have since made changes at the home to ensure the snack trolley has suitable food for all residents and training has also taken place.
Alistair Duncan, head of the Health and Safety Investigation Unit of the Crown Office and Procurator Fiscal Service, said: “The death of this vulnerable care home resident could have been prevented if suitable training and procedures were in place.
“HC-One Limited left all residents at risk by failing to ensure modified diets were adhered to and staff had the relevant knowledge to keep those in their care safe. This prosecution should reiterate the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.
“Our thoughts are with the family of the resident at what must be a difficult time for them.”
James Tugendhat, chief executive officer of HC-One said: “First and foremost, we offer our heartfelt condolences and apologies to [the resident’s] family and loved ones.
“It was vitally important to us that lessons were learned when this occurred in 2019. Additional safeguards are now in place across all our homes to prevent a repeat of an accident like this, and colleagues now complete additional and specific training focused on supporting residents who have modified diets.
“The Care Inspectorate has recognised this work across our homes, as well as the very good care provided at The Orchard today.
“We are clear that this tragedy should never have happened, and we hope today’s judgement provides [the resident’s] family with some comfort and closure.”