A Hampshire care home provider has been fined following an incident in which a man died following a choking incident while eating his meal.
Buckland Care Limited, which ran a care home called Merry Hall Nursing and Residential Care Home, now called Hartwell Lodge in Fareham, Hampshire, was fined £80,000, ordered to pay £16, 305 prosecution cost, plus a £170 victim surcharge at Portsmouth Magistrates Court on 1 December in a prosecution brought by the Care Quality Commission (CQC).
The company pleaded guilty to failing to provide safe care and treatment, resulting in avoidable harm, to Mr Alec Marshall at Merry Hall in March 2017.
The court heard that Mr Marshall required assistance to cut up his food and that he should be monitored during meal times. It was mentioned in Mr Marshall’s risk records and support plans that his meals should be cut up into small, bite size amounts. However, it did not give any guidance as to what dimensions would make up a bite size amount or what was meant by monitoring.
The daily handover sheet used on 12 March 2017 identified the risk of choking and that Mr Marshall needed assistance to cut up his food, but it did not explain the requirements for monitoring or that food should be cut up into small pieces.
On 12 March 2017 Mr Marshall was given his lunch and was left alone in his bedroom at Merry Hall. Shortly after this, he was found in his room, unresponsive. Paramedics were called and removed an approximately 2 inch by 1 inch piece of meat from Mr Marshall’s throat. Resuscitation was unsuccessful and Mr Marshall was pronounced dead at the scene.
Buckland Care Limited failed to provide safe care in two respects: care documentation did not give enough guidance in relation to the choking risk and the handover process on 12 March 2017 did not properly cover the measures in place to protect Mr Marshall in relation to a risk of choking.
Rebecca Bauers, Head of Adult Social Care Inspection in CQC’s south region, said:
“This is a distressing case, and our thoughts and sympathies are with Mr Marshall’s family. He had every right to expect good, quality care and it is right that the provider has accepted responsibility in this case.
“It was the serious failure of the home to protect Mr Marshall from avoidable harm that led to CQC’s prosecution of the provider. In their role as provider Buckland Care Services had a specific legal duty to ensure care and treatment was provided in a safe way. We found they had failed to do this by not ensuring risks had been fully assessed and measures were not in place to prevent harm.
“Where we find any care provider has put people in its care at serious risk of harm, we will take action to ensure that people are safe and hold providers to account.”
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