Care home fined £170,000 after resident choked to death
The UK’s biggest care home provider has been fined £170,000 after a resident choked to death on fish and chips during an entertainment evening.
Four Seasons Health Care (England) Ltd was prosecuted by HSE after an investigation found that vulnerable resident, Rita Smith, should only have been provided with pureed food as she had swallowing difficulties and was at risk of choking.
Preston Crown Court heard that the 75-year-old, who suffered from dementia and motor neuron disease, was admitted into Euxton Park Care Home in November 2010. The home was made aware that Miss Smith had difficulty swallowing, needed pureed food on a teaspoon and supervision by a carer while eating.
However, only two weeks later, Miss Smith was given fish and chips in a cone along with the other residents during a film and supper evening in the care home on 1 December 2010.
When a member of staff began clearing up the meals during the film, she noticed Miss Smith was slumped in her chair. A nurse attempted to resuscitate her but she was later pronounced dead. A post mortem found the primary cause of death was choking.
The HSE investigation into the incident found neither of the staff who organised the film and supper evening had been made aware that Miss Smith could not eat solid foods.
A specialist assessment carried out at a local hospital, recommending she be supervised at meals and prompted to slow down and swallow twice during each mouthful, had been provided to the care home but was not communicated to staff.
A care plan and risk assessment had also not been completed by Four Seasons for Miss Smith on her arrival at the home, which would have identified the need for a care worker to feed her pureed food during meal times.
It also emerged that a carer at the home had left Miss Smith alone to eat un-pureed Weetabix a few days before the film and supper evening.
Four Seasons Health Care (England) Ltd, part of the Four Seasons Health Care group which runs more than 500 care homes and specialist care centres in the UK, pleaded guilty to breaching section 3(1) of the HSWA 1974.
The company, of Groves Road in Douglas, Isle of Man, was fined £125,000 and ordered to pay £45,000 in costs.
Following the hearing, HSE inspector Shellie Bee, said: “This was a tragic death which could have been avoided if Four Seasons Health Care had made sure systems were in place to protect residents. As it was, a vulnerable and elderly woman paid the price for their failures.
“Our investigation found there had been an alarming lack of communication with many staff unaware of Miss Smith’s medical needs, despite them being well-documented.
“She should never have been given un-pureed food, let alone been left by herself to eat it during the film and supper evening. But her condition meant she did not have the mental capability to refuse the meal or recognise the danger.
“Euxton Park Care Home was made aware of the risk of Miss Smith choking on un-pureed food when she arrived, but failed to act properly and as you would expect on this information. Sadly, she lost her life as a result.”
Miss Smith’s family also released the following statement: “We are grateful to the HSE for the professional and sensitive way in which they have liaised with our family following the disgraceful and unnecessary death of Rita, three years ago.
“Rita was in Euxton Park Care Home for a mere two weeks before this frightening and tragic event occurred.
“Our hope is that the seriousness and financial implications of this case for the company will ensure that nothing like this will ever happen again at a Four seasons or any other care home. This would mean that Rita’s tragic death will not have been entirely in vain.”
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Care home fined £170,000 after resident choked to death
The UK's biggest care home provider has been fined £170,000 after a resident choked to death on fish and chips during an entertainment evening.
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The UK’s biggest care home provider has been fined £170,000 after a resident choked to death on fish and chips during an entertainment evening.
Disgraceful that robust care plans weren’t in place.
Disgraceful, unprofessional and neglectful practice by this care company, which sadly resulted in this lady’s death. Horrendous for her and her family.