HC-One Limited has been fined £640,000 after an incident in which a resident at one of its homes choked to death on a jam doughnut.
Risk Assessment Failings
Falkirk Sheriff Court heard that, on 7 August 2019, a resident of Orchard Care Home on Lychgate Road in Tullibody, was given a piece of jam doughnut to eat. The resident had previously suffered from a stroke and had been diagnosed with dementia. She had been assessed as being at high risk of choking and consequently was on a ‘minced and moist/fork mashable’ diet. A jam doughnut is unsuitable for someone on this diet and should not have been given to her. She died as a result of choking on the doughnut.
An investigation by the Health and Safety Executive (HSE) found that staff who gave out snacks to residents at Orchard Care Home had not been properly trained and did not have awareness of food that was suitable for each diet. It was found that this resident was regularly served food that was not suitable for her diet, in breach of the care home’s own risk assessment.
HC-One Limited of Southgate House, Archer Street, Darlington, County Durham DL3 6AH pleaded guilty to breaching the Health and Safety at Work etc. Act 1974, Section 3(1) and Section 33(1)(a) and were fined £640,000.
After the hearing, HSE inspector, Allison Aitken said: “Those in control of work have a responsibility to devise safe methods of working and to provide the necessary information, instruction and training to their workers in the safe system of working
“If a suitable training had been in place prior to the incident, the sad death of a resident could have been avoided.”
HC-One Limited Statement
James Tugendhat who is chief executive officer of HC-One provided a statement: “First and foremost, we offer our heartfelt condolences and apologies to Mrs Hughes’ family and loved ones.
“It was vitally important to us that lessons were learned when this occurred in 2019.”
Tugendhat revealed there are now additional safeguarding procedures in place and specific training around resident diets across all of the homes to prevent a repeat of the accident.