Inverness care home fined over £1.8 million after resident choked to death on evening meal

Margaret Campbell, a 96-year-old woman who was a resident in Cradlehall Care Home in Inverness in June 2022, was left to eat alone after being served a meal of macaroni and chips, despite her care plan stating that she should be closely supervised at meal times.

Ms Campbell, who was known as Peggy, choked on a piece of food after her carer left the room for around 20 minutes.

HC-One Limited, who run the care home, pleaded guilty to failings under health and safety at work legislation and were sentenced at Inverness Sheriff Court on Monday.

At the time of her death, the unit was staffed by two agency carers who had responsibility for 12 residents.

Ms Campbell, who was on a specialist diet of soft, moist and bite-sized food, was served the meal at 5.45pm while sitting up in bed.

Her carer left to get a drink to accompany her meal, but was then forced to deal with issues concerning two other residents, which required her to call for assistance from another unit.

As a result of the disruption, the 96-year-old was left on her own for up to 20 minutes before the carer returned.

When the carer arrived back at the room, they raised the alarm and other staff came to assist.

A paramedic who arrived shortly afterwards pronounced Ms Campbell dead.

The company pleaded guilty under the Health and Safety at Work etc Act 1974 and were over fined £1.8 million, with a £135,000 victim surcharge.

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service, said:

"The death of this vulnerable woman could have been prevented if a safe system of work were in place to ensure that on any occasion she ate a meal, she was subject to an appropriate level of supervision.

"HC-One Limited‘s failure left all residents at risk. This prosecution should reiterate the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.

"Our thoughts are with the family of the resident at what must be a difficult time for them."

A spokesperson for HC-One Scotland said: “We would like to extend our deepest condolences and sincere apologies to the family of Mrs Campbell at this difficult time. The safety and wellbeing of all our residents is our highest priority, and we have been shocked and saddened by the events that transpired in 2022.

“Following this tragic incident, we undertook an immediate and thorough investigation, implementing comprehensive steps to address the shortcomings that led to Mrs Campbell’s death. We have ensured that lessons are learned across the organisation, and we are committed to maintaining and delivering the highest safety and quality care standards.

“In collaboration with experts across a broad academic spectrum, we have embarked on a detailed research project outlining the risks and steps to carefully manage said risk around a choking incident, the findings of which continue to be shared and reinforced across the organisation.

“We are clear that this incident should never have happened, and we hope that today’s conclusion can bring a sense of closure to those who knew and loved Mrs Campbell.”