Care Home Fined After Vulnerable Resident Chokes

Elderly Dementia Sufferer Was Supposed To Eat Pureed Food

17.03.2014

Four Seasons Health Care - the UK's largest care home provider - has been fined £125,000 after an elderly dementia sufferer choked to death.

Rita Smith, aged 75, was given fish and chips in a cone by staff at Euxton Park Care Home in Chorley, Lancashire in December 2010.

A specialist assessment undertaken at a local hospital had previously found she had difficulty swallowing, so a plan was put together to ensure she only received pureed food and was supervised.

However, this was not conveyed to staff and they were unable to revive Miss Smith when she was found slumped in her chair during the entertainment evening.

An investigation by the Health and Safety Executive (HSE) also found that a risk assessment had not been carried out when the resident arrived at the home.

The regulator revealed that she had been given an un-pureed Weetabix just a few days prior to the incident.

Having pleaded guilty to a single breach of the Health and Safety at Work etc Act 1974 during a hearing at Preston Crown Court, Four Seasons Health Care, of Groves Road in Douglas, Isle of Man, was also forced to pay £45,000 in costs.

There has been a lot of debate surrounding standards of care in the UK of late, particularly in homes that have a number of residents who suffer from dementia.

HSE inspector Shellie Bee said this tragic incident could have been avoided had the firm made sure systems were in place to protect residents.

"As it was, a vulnerable and elderly woman paid the price for their failures," she commented.

"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."

A statement from Miss Smith's family also confirmed that she had only been in the care home for two weeks before the incident.

They said they hope this case highlights the severe consequences of failing to protect vulnerable residents and that this never happens again.

Expert Opinion
News of this prosecution is hugely disturbing and we would urge the care home provider involved – as well as all organisations involved in the care of vulnerable adults – to ensure that lessons are learned from this awful tragedy.

"A huge number of families put their faith in health and social care services to ensure their loved ones get the best possible around-the-clock support and care, and an incident of this nature only serves to damage the trust and confidence that people have in residential and care facilities.

"The safety of residents should always come first and a key part of that is proper communication among staff. These problems simply cannot be repeated."
Mandy Luckman, Partner