Care Home Fined £170,000 After Vulnerable Resident Choked to Death

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Posted on 13 Mar 2014

The UK’s biggest care home provider has been ordered to pay £170,000 in fines and costs after a vulnerable resident choked to death on fish and chips during an entertainment evening.

Four Seasons Health Care (England) Ltd (“Four Seasons”) was prosecuted by the Health and Safety Executive (HSE) after an investigation found that the resident should only have been provided with pureed food as she had swallowing difficulties and was at risk of choking. The home had been made aware that she had difficulty swallowing and needed pureed food on a teaspoon and supervision by a carer while eating.

However she was given fish and chips in a cone along with other residents while she was at a film and supper evening in the care home. The HSE investigation into the incident found neither of the staff who organised the film and supper evening had been made aware that she could not eat solid foods.

A specialist assessment carried out at the 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 be completed by Four Seasons for the resident on her arrival at the home, which would have identified the need for a care worker to feed her pureed food during meal times.

Four Seasons pleaded guilty to a single breach of the Health and Safety at Work etc Act 1974 and was fined £125,000 and ordered to pay £45,000 towards costs.


Care homes are not only a work environment but also a person's home environment, so the risk assessment must be dynamic to meet the needs of individuals’ vulnerabilities and risks. There can be wide ranging and complex medical issues such as dementia, restricted mobility, reduced sight and hearing and special needs. Many residents will very likely be taking medication to manage their medical conditions and these may potentially cause further vulnerabilities. In addition to these complex needs are the specific care home hazards such as bed rail entrapment, falls off beds and hoists, falls from height from windows, slip, trips and falls down stairs and burns from hot water and hot radiators.

Risk assessments are required on the unique and complex work environment for the staff and others who work within the care home environment. In addition, the risk assessment needs to identify specific hazards in the care home environment against the vulnerabilities of each resident. Changes in level on a floor or walking down stairs with no handrails can potentially cause a resident to trip or fall due to reduced mobility or reduced sight.

Further individual risk assessments and supporting care plans are required on each resident to identify their particular needs and ensure controls are in place to manage all risks to them within the care environment. These individual risk assessments must record the complex needs and dependency of the frail elderly. All aspects of their personal needs require review, including but not limited to eating and drinking, mobility, sight and hearing. All outcomes of their risk assessment must be communicated to staff, including agency staff and others, such as members of the multi disciplinary team who are potentially providing care. A structured, focused co-ordinated approach by all staff is required when working with and caring for elderly residents.

Further information can be found on the HSE website and in the Department of Health’s National Minimum Standards for Care Homes for Older People.

Doyle Clayton can support your care/resident/nursing home with ensuring the development and review of Health and safety procedures that will take into account this complex environment. Please contact Sally Beck who is also both a registered nurse and Chartered Health and Safety professional and experienced in this unique area.

The articles published on this website, current at the date of publication, are for reference purposes only. They do not constitute legal advice and should not be relied upon as such. Specific legal advice about your own circumstances should always be sought separately before taking any action.

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