Nursing home fined £20k after resident (87) chokes to death

Nursing home fined £20k after resident (87) chokes to death

28 September 2022

A LOCAL care home owner has been fined £20,000 after an elderly resident died after choking on a pancake.

M Care Ltd, of Main Street, Ballynahinch, had previously pleaded guilty to a charge of failing to ensure the safety of a non-employee at Ringdufferin Nursing Home outside Killyleagh under health and safety regulations.

Last Thursday, Downpatrick Crown Court, sitting in Belfast, heard that Mr Edward McCullough (87) had been a resident at the home from July 2015.

Prosecution barrister Laura Ivers told Judge Geoffrey Miller KC that on his admission to the home a dietary care plan was drawn up for Mr McCullough, as he was assessed as being at risk of choking.

The care plan outlined that Mr McCullough was to receive mashed or pureed food and liquid only and “no bread was to be permitted’’.

Ms Ivers said that on November 21, 2016, the pensioner was noted by staff to be restless and it was decided to move him to an area beside the nurses’ station, but a care assistant wheeled him into the activities room where an external contractor was conducting a bakery class for some residents.

“Unfortunately, the external co-ordinator of the bakery class gave Mr McCullough a freshly baked pancake and he ate it. It was not pureed,’’ said Ms Ivers.

“A short time later she realised he was struggling to swallow. A nurse performed first aid but despite efforts by staff and paramedics, Mr McCullough died some time later in his private room.’’

The court heard that by its guilty plea M Care Ltd accepted that it had a duty to ensure that the external co-ordinator was made aware that “under no circumstances was Mr McCullough to be given a pancake unless it was pureed’’.

Defence counsel Frank O’Donoghue KC, on behalf of the residential home, said that this was the first breach of health and safety regulations by the company.

He said the company took such breaches “very seriously’’, had an “excellent care record’’, and had since implemented and improved measures at the home to prevent any repetition.

“The company acknowledges the emotions and the hurt that have been expressed most eloquently in the course of victim impact statement from Mr McCullough’s children,” he said.

“This is a very tragic case in which a much-loved gentleman who had a very valued life providing great service to his family and the local community who lost his life in circumstances which should have not occurred.

“The circumstances by which he died are extremely distressing to the family and the company fully acknowledges that everyone has been deeply affected by it. Mr McCullough was much loved within the home and staff members in the home have also been deeply affected by this case.’’

Before passing sentence, Judge Miller KC referred to the detail of victim impact statements submitted by the prosecution and prepared on behalf of Mr McCullough’s son and daughter.

He said Mr McCullough was a much loved family man and and that in the statements his childrenspoke of their shock at the manner of their father’s tragic death.

“This sense of shock appears to have been compounded by what was perceived to be a less than caring response by individual members of staff. This court recognises that an unfortunate choice choice of words or demeanour can lead to added hurt; it can also be that those words and the intention behind them can be misconstrued.”

Judge Miller said the prosecution submitted this was case of “medium culpability” in that M Care Ltd “fell short of the standards expected” and that while systems were in place, these were not sufficiently adhered to nor implemented.

He said that the breach of care was “significant” as the risk of serious injury was clearly foreseeable as a vulnerable patient was fed food stuffs other than those specified in his food plan.

“Mr McCullough was an elderly man and in failing health in the last years of his life. Nevertheless, his death and the manner of it was both untimely and distressing and his family have been caused understandable hurt, not least by virtue of the time that has elapsed between his death and the instigation and eventual conclusion of these proceedings.

“Nothing that this court says or does can undo what has been done and the imposition of a fine, whether large or small, cannot restore the life that has been lost,” Judge Miller continued.

He said the court had to make an assessment of the degree of culpability and impose the penalty it considers appropriate.

“The breach was significant as the risk of serious injury was clearly foreseeable in circumstances were a vulnerable patient such as Mr McCullough was fed foodstuffs other than those specified in his food plan,” he said.

Judge Miller said the incident at the care home was isolated and the result of “inadvertent neglect”, with an individual member of staff not knowing the details of Mr McCullough’s care plan and that he could not be given food that he could not digest.

Outside the court, Kyle Carrick, head of the Northern Ireland Health and Safety Executive’s major investigation team, said: “Choking can result in serious and fatal injuries and is avoidable in cases where there is a known risk.”

He added: “Effective communication of patient requirements to all relevant staff is vital to ensure patient safety.

“In this case, the failure to effectively communicate dietary restrictions of Mr McCullough resulted in his tragic death which was avoidable.”