Fatal Accident Inquiry Reveals Care Home Error
A care home resident died after being mistakenly served steak pie instead of his prescribed textured diet meal, a fatal accident inquiry (FAI) has determined.
Robert McPaul passed away on 30 March 2018 at Sir Gabriel Wood's Mariners' Home in Greenock. The 70-year-old was on a textured diet, which required him to consume only soft foods.
Sheriff Sheena Fraser found that the care home lacked an adequate system to help staff identify residents with specific dietary requirements or to verify that residents received the correct meals.
The Sailors Society, owners of the home, opted to close the facility in 2020, two years after McPaul's death.
Resident Background and Incident Details
McPaul had been residing at the care home since 2009. He suffered from osteoarthritis and chronic oedema and had a history of choking on food. He was placed on a texture diet in December 2017.
On the day of his death, the menu listed two dishes suitable for a textured diet: beef stew and chicken paella. McPaul selected the chicken paella but was mistakenly served steak pie. He choked on a piece of puff pastry from the pie.
Despite efforts to revive him and relieve the choking, McPaul died at the scene.
Sheriff Fraser stated it was unclear how McPaul was served the incorrect dish and suggested the error was likely due to human error by staff on duty that day.
"A system of work relying on a handwritten menu being checked by one individual carer before distributing meals is not sufficiently robust and I consider it to amount to a defect in the system of work."
Issues with Meal Identification and Staff Training
At the time of the incident, one care worker assisting McPaul had been employed for less than three months and had not yet received training in food and nutrition, including knowledge of residents' dietary needs. She was shadowing a more experienced staff member when the choking occurred.
The FAI revealed that the head cook or assistant prepared individual meals, which were then transported to the dining room along with a handwritten menu. Sheriff Fraser noted there was no specific order for arranging meals on the trolley's two levels, and plates were not labeled with residents' names.
"There was no particular order to the way in which the meals were set out over the two levels of the trolley, and there was no name marked on any of the plates."
"There was no evidence to suggest that the steak pie dinner was one which was suitable for someone on such a diet, and it was not the meal selected by Mr McPaul for his dinner that night."
Following McPaul's death, the care home introduced a system placing different meal types on coloured plates, with the colour coding also indicated on the menu sheet. This change aimed to make meal types more easily identifiable.
Closure of the Care Home
The FAI did not issue recommendations for future practice as the care home has since closed. The closure followed a comprehensive review prompted by a significant decline in mariner beneficiaries and concerns about the resources necessary to maintain the facility.
The last residents left the home in February 2021, and the trustees are no longer involved in operating any care homes.
