£100k fine for care company after tragic death of woman

A supported housing company has been fined £100k after a disabled woman in their care died after choking on a marshmallow.

Shirley Breeze, who had severe learning disabilities, as well as being diagnosed with epilepsy and dyspraxia was in the care of Ark Housing Association Limited when the incident happened at her home address in Cowdenbeath, Fife.

Kirkcaldy Sheriff Court heard how the 64-year-old was given the marshmallow – which was an unsuitable food item for her prescribed diet – by one of the company’s support workers on 30 November 2019.

Miss Breeze began to choke soon afterwards and although the support worker correctly followed first aid procedures, was unable to dislodge the marshmallow. The support worker carried out CPR until paramedics arrived to provide additional emergency assistance. Paramedics were successful in removing the marshmallow, but Miss Breeze then suffered two cardiac arrests and a seizure, which led to her being placed in an induced coma. She passed away on 2 December 2019.

An investigation carried out by the Health and Safety Executive (HSE) found that Miss Breeze had been the subject of an assessment by Speech and Language Therapy following a prior choking incident. It was advised that she be placed on ‘a Texture Type E (soft) diet’. There was evidence that requirements of her Type E diet were not known, understood, or implemented by all of her support workers. Ark Housing Association Limited failed to provide support workers with adequate training to ensure that all aspects of a Type E diet, now known as an IDDSI Level 6 diet, were understood and followed.

Ark Housing Association Limited pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 and were fined £100,000.

Speaking after the case HM Inspector, Kerry Cringan said “This was a tragic and deeply upsetting incident for all involved, particularly the team who had cared for Miss Breeze for many years.

“Ark Housing Association Ltd had identified the risk of choking and had taken steps to ensure the care plan reflected this risk.

“However, they failed to provide support workers with adequate training so that they understood the foods textures that would pose a challenge for Miss Breeze.

“This failing ultimately led to the death of a vulnerable person.”

Source HSE Website | 09.02.2023

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