On 7th August 2019, a resident of Orchard Care Home 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 HSE found that staff who gave out snacks at Orchard Care Home had not been properly trained and did not have awareness of food that was suitable for each diet. They regularly gave this resident food, which was not suitable for her diet, in breach of their own risk assessment.
HC-One Limited of County Durham 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.”
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