A care home company has been fined more than half a million pounds after one of its residents choked on a piece of doughnut and died.
The 65-year-old woman, of Orchard Care Home in Tullibody, Clackmannanshire, was on a specialist diet of minced and moist foods after a severe stroke and vascular dementia left her at risk of choking.
Her modified diet meant bread products were not suitable, according to an NHS leaflet.
On August 7 2019, however, she was given a piece of jam doughnut as a snack from a tea trolley, which she choked on.
Despite efforts of care home staff and paramedics to remove the food, the resident died.
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HC-One Limited, which runs the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974 and was fined £640,000 at Falkirk Sheriff Court on Wednesday.
Alistair Duncan, head of the Health and Safety Investigation Unit of the Crown Office and Procurator Fiscal Service, said the death could have been prevented “if suitable training and procedures were in place”.
Main meals at the home were labelled with each resident’s name, but the snack trolley did not have information on those who were required to avoid certain foods, the court heard.
Staff in charge of the trolley had also not been given sufficient training on modified diets.
The hearing also found prior to the resident’s death, she had frequently been given sandwiches from the snack trolley, which repeatedly put her at risk of choking.
HC-One Limited, which has more than 300 care homes in the UK, has since made changes to its health and safety measures at the home to ensure the snack trolley has suitable food for all residents, and further training of staff has been introduced.
Mr Duncan said: “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) Mrs Hughes’ family and loved ones.
“It was vitally important to us that lessons were learned when this occurred in 2019.”
Mr Tugendhat confirmed additional safeguards are now in place across all HC-One’s care homes to prevent a similar death, and staff now complete additional and specific training focused on supporting residents who have modified diets.
“We are clear that this tragedy should never have happened, and we hope today’s judgement provides Mrs Hughes’ family with some comfort and closure,” he added.