Care home fine tripled to £60,000 over cleaning fluid death

August 29, 2023

(Scotland)
A care home where an Alzheimer’s resident died after drinking cleaning fluid has had its £20,000 fine tripled by an appeal court.

Judges ruled the original penalty over David Fyfe’s death was “unduly lenient” and raised it to £60,000.

The 90-year-old died from ammonia poisoning four days after drinking the substance at Tigh-Na-Muirn in Monifieth, Angus, in 2020.

The unlabelled bottle was stored on top of a bathroom cabinet in his room.

The company responsible for the home, Tigh-Na-Muirn Ltd, pleaded guilty to breaching health and safety laws at Dundee Sheriff Court earlier this year.

Imposing the original sentence, Sheriff Jillian Martin-Brown took into account mitigatory factors, including the “extremely challenging circumstances” facing staff during the COVID pandemic. She also described it as an “isolated incident”.

However, lawyers for the Crown argued that too much weight had been given to mitigation, and the sheriff had taken the wrong approach to sentencing.

In a written judgement, appeal court judge Lady Wise wrote: “The sheriff gave inadequate consideration to the degree of risk and the extent of the danger, and failed to recognise that the breach was not an isolated incident but continued over a period of time.

“The offence occurred in a care home when the COVID-19 pandemic was at its full height and when care homes in particular were operating under enormous pressure.

“We also recognise that the offence occurred as a result of staff attempting to ensure that residents were kept safe by minimising items coming in and out of resident’s rooms and possibly spreading infection.

“Nevertheless, we consider that the fine imposed by the sheriff failed to fulfil sufficiently the relevant sentencing objective of punishment and deterrence.”

Risk assessment

The company running the home employs 120 staff, looking after 59 residents, and has an annual turnover of up to £10m.

At the time of the poisoning, Mr Fyfe had contracted COVID and was confined to his room. After being found unwell, he was transferred to Ninewells Hospital in Dundee but his condition deteriorated and he died on 31 May 2020.

A post-mortem examination found the primary cause of death was ingestion of an ammonia-based cleaning fluid called Steri Germ.

In her judgement, Lady Wise said such hazardous substances had previously been locked in a cupboard, but for two-and-a-half months prior to Mr Fyfe’s death those precautions had been breached.

She said an appropriate risk assessment could have resulted in a safe way of storing such substances during the pandemic, such as keeping them in a locked box outside residents’ rooms.

This is valid as of 29th August 2023.

(Scotland)
A care home where an Alzheimer's resident died after drinking cleaning fluid has had its £20,000 fine tripled by an appeal court.

Judges ruled the original penalty over David Fyfe's death was “unduly lenient” and raised it to £60,000.

The 90-year-old died from ammonia poisoning four days after drinking the substance at Tigh-Na-Muirn in Monifieth, Angus, in 2020.

The unlabelled bottle was stored on top of a bathroom cabinet in his room.

The company responsible for the home, Tigh-Na-Muirn Ltd, pleaded guilty to breaching health and safety laws at Dundee Sheriff Court earlier this year.

Imposing the original sentence, Sheriff Jillian Martin-Brown took into account mitigatory factors, including the “extremely challenging circumstances” facing staff during the COVID pandemic. She also described it as an “isolated incident”.

However, lawyers for the Crown argued that too much weight had been given to mitigation, and the sheriff had taken the wrong approach to sentencing.

In a written judgement, appeal court judge Lady Wise wrote: “The sheriff gave inadequate consideration to the degree of risk and the extent of the danger, and failed to recognise that the breach was not an isolated incident but continued over a period of time.

“The offence occurred in a care home when the COVID-19 pandemic was at its full height and when care homes in particular were operating under enormous pressure.

“We also recognise that the offence occurred as a result of staff attempting to ensure that residents were kept safe by minimising items coming in and out of resident's rooms and possibly spreading infection.

“Nevertheless, we consider that the fine imposed by the sheriff failed to fulfil sufficiently the relevant sentencing objective of punishment and deterrence.”

Risk assessment

The company running the home employs 120 staff, looking after 59 residents, and has an annual turnover of up to £10m.

At the time of the poisoning, Mr Fyfe had contracted COVID and was confined to his room. After being found unwell, he was transferred to Ninewells Hospital in Dundee but his condition deteriorated and he died on 31 May 2020.

A post-mortem examination found the primary cause of death was ingestion of an ammonia-based cleaning fluid called Steri Germ.

In her judgement, Lady Wise said such hazardous substances had previously been locked in a cupboard, but for two-and-a-half months prior to Mr Fyfe's death those precautions had been breached.

She said an appropriate risk assessment could have resulted in a safe way of storing such substances during the pandemic, such as keeping them in a locked box outside residents' rooms.

This is valid as of 29th August 2023.

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