HSE | A Selkirk care company has been fined after a resident choked to death on food that had not been prepared in accordance with his dietary requirements.
Thomas Telford, known as Barry, aged 86, choked during lunch at Riverside Healthcare Centre, Bridge Street, Selkirk. Mr Telford had been a resident at the home since 9 May 2023, having been admitted directly from Kelso Community Hospital. He had a complex medical and a well-documented history of dysphagia — difficulty swallowing — that had been identified as far back as November 2019.
Mr Telford had been assessed as requiring a Level 5 (minced and moist) diet under the International Dysphagia Diet Standardisation Initiative (IDDSI), meaning all food should be minced into small moist pieces no greater than 15mm in length and 4mm wide. His care plan also required that he be supervised at mealtimes due to his tendency to overfill his mouth and eat quickly, and he had been identified as being at high risk of choking.
At lunchtime on 25 May 2023, Mr Telford was served a meal of beef, mashed potato and cabbage. The beef served to him had not been prepared in accordance with his Level 5 dietary requirements. A carer supervising the dining room noticed his lips turning blue and immediately raised the alarm. Backslaps and abdominal thrusts were administered, and an ambulance was called. He was pronounced dead at Borders General Hospital at 14:00 hours.
Investigating, the HSE found that Riverside Care Limited had failed to ensure a sufficiently robust system of work for the preparation and serving of texture-modified meals. Whilst the home operated a broadly suitable system of serving either normal or modified meals, and staff had received training on dysphagia and the IDDSI framework, that system had failed on the day in question. As a result, Mr Telford was served food that was not safe for him to consume.
Riverside Care Limited, of Bridge Street, Selkirk, pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc. Act 1974 and was fined £16,000.
After the hearing, HSE Inspector Robbie Morrison, said: “Mr Telford’s need for a texture-modified diet was well documented and well known to those caring for him. He had a history of dysphagia and had been clearly identified as being at high risk of choking.”
“Employers have a duty to ensure that the systems they put in place to protect the people in their care are robust enough to work consistently and without fail. In this case, that system was not sufficiently robust, and the consequences were fatal.”
“This was a tragic and entirely preventable death. We hope this case serves as a reminder to all care providers of their responsibility to ensure that residents with complex dietary needs receive only food that is safe for them.”
