Head Of Training, The Healthy Work Company

January 15, 2016

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Choking death: Safeguards were not implemented

Shropshire Council has been prosecuted after the death of a vulnerable day visitor to one of its care centres.

Shrewsbury Crown Court heard Michael Breeze, 53, who had a history of choking incidents, choked while eating his lunch on 5 September 2012 at council-run day services centre Hartley’s Day Centre, in Shrewsbury.

Prosecuting, the Health and Safety Executive (HSE) told the court Hartley’s Day Opportunity Centre caters for adults with learning disabilities. Mr Breeze was taken to the centre for the day with a packed lunch provided by carers at the residential home where Mr Breeze lived.

At around midday Mr Breeze began to eat his lunch when he started to choke and collapsed. Staff at the centre went to Mr Breeze’s assistance, who by then appeared to have gone into respiratory arrest.

CPR was commenced and paramedics were called. On arrival of paramedics attempt was made to intubate, this was difficult due to food in the trachea.

Mr Breeze, who lived at a care home in Sutton Bank, was rushed to the Royal Shrewsbury Hospital and further CPR was carried out with two lots of adrenaline being given. However, Mr Breeze did not recover.

It was heard that Mr Breeze had a history of choking incidents at both his residential home and day services and HSE argued that appropriate safeguards were not implemented at Hartley’s Day centre despite these warnings.

Shropshire Council admitted breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. The council was fined £25,000 and ordered to pay £39,317 in costs.

Judge Robin Onions said he had considered Shropshire Council’s financial position and the impact of a fine on the authority’s ability to provide vital services, and said a financial report “made bleak reading” for the prospects over the next five years.

He also made it clear that Mr Breeze’s death was a failure of the system and not the fault of any individuals who cared for him.

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