Care home company fined after care home resident choked and died

February 1, 2022

[Scotland] A care home company has been fined £640,000 after one of their residents choked on a piece of doughnut and died.

The 65-year-old resident of Orchard Care Home in Tullibody, Clackmannanshire was on a specialist diet of minced and moist food after a severe stroke and vascular dementia left her at risk of choking.

However, on 7 August 2019, she was given a piece of jam doughnut as a snack from the tea trolley, which she choked on. Despite the efforts of care home staff and paramedics to remove the food, the resident died.

HC-One Limited, who run the care home, 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.

The resident was on a minced and moist diet since being assessed as having a high risk of choking on 2 December 2018. Bread products are not suitable for this modified diet as they cannot be mashed small enough.

Prior to her death, the resident had frequently been given sandwiches from the snack trolley, repeatedly putting her at risk.

Main meals at the home were prepared by the kitchen and labelled with each resident’s name. However, the snack trolley did not have information on modified diets or food suitability. Staff in charge of the trolley had also not had 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. 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.”


This is valid as of 1st February 2022.

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