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Care homes pay the price of inadequate choking risk assessment and training

Care homes are reminded of their legal duties regarding reducing the risk of adverse choking incidents.

In an article Brodies law firm reflects on a number of recent cases where care home operators have been found liable for the deaths of residents who choked to death on solid foods, despite having been placed on ‘soft diets’.  

These cases are as follows:

  1. HC-One Limited was fined £640,000 in January 2022 after a resident at a care home in Clackmannanshire choked to death on a piece of jam doughnut given to her by staff. The resident suffered from dementia and had recently had a stroke. Risk assessments were carried out which confirmed that she was at high risk of choking, she was therefore placed on a diet of minced and moist food. The staff member who gave her the piece of jam doughnut had not been given training on modified diets or any information about the suitability of certain foods. Falkirk Sheriff Court therefore found that HC-One Limited failed to discharge their legal responsibilities to effectively communicate with staff and provide appropriate training.
  2. Care UK Community Partnerships Limited was fined £1.5 million in April 2018 after an elderly resident at a care home in West Sussex choked to death on large pieces of meat given to him by staff. The resident had recently been admitted to hospital, where a speech & language therapist determined that he should be put on a soft diet due to him being at risk of choking. Crawley Magistrates’ Court found that the care operators did not keep accurate records and failed to take account of the advice given by the speech therapist when carrying out subsequent risk assessments. In one such risk assessment carried out by staff members at the home, following the resident’s discharge from hospital, no choking risks were noted.
  3. A final example comes from a nursing home in Killyleagh Northern Ireland, where a resident choked to death on a pancake which was given to him by a self-employed activities manager. The gentleman was known to have difficulties swallowing and therefore to be at risk of choking. He was placed on a pureed diet as a result. The home’s operator, M Care Limited, was fined £20,000 in September 2022 for failing to effectively communicate the resident’s dietary requirements to the activities manager.

Legal Duties

Care home operators have a legal obligation to, so far as is reasonably practicable, ensure the safety of their residents. In practical terms, this means that operators have a responsibility to:

  • Carry out risk assessments in relation to their residents
  • Effectively communicate with staff members so that they know about the risk assessments and the specific needs of each individual resident.
  • Ensure that staff members are appropriately trained and know how to implement the risk assessments.

Care homes should also ensure there is regular auditing and review of assessments to ensure they are still appropriate.


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