Featured Image Credit: Google Maps
Topics: UK Food
Ben Williams
A tragic care home case in Scotland has resurfaced after a formal ruling laid out how a 70-year-old resident died when he was served the wrong evening meal.
Robert McPaul lost his life at Sir Gabriel Wood’s Mariners’ Home in Greenock on 30 March 2018, but the details of what happened have now been revisited in a fatal accident determination that points to serious failings around meal checks, dietary requirements, and staff systems inside the home.
Cases like this are always difficult to read because they centre on something that should have been straightforward. In a care setting, meals are tied directly to a resident’s health, mobility, and medical history, as well as being part of their daily routine; in some cases, special requirements need to be accommodated for them to eat safely at all.
Advert
That was especially true for McPaul, who was on a Texture D diet and was only supposed to be given soft foods. The determination states that he was instead handed a steak pie for dinner, despite that meal not fitting his dietary needs and despite the fact that he had apparently chosen something else from the menu.
The fatal detail was that the pastry from the pie lodged in his trachea and caused him to choke to death.
Sheriff Sheena Fraser found: “The primary cause of death was choking on food, with cerebrovascular disease being a potential contributing cause.”
The case becomes even more upsetting when you get into the background. McPaul had cognitive impairment and lived in the home’s Korsakoff Unit, which cared for residents with Korsakoff syndrome — a disorder impacting the memory that’s caused by a major thiamine deficiency, as reported by People.
He was also known to have had difficulty swallowing, previous choking incidents, and problems with eating too quickly. The determination said he was ‘relatively immobile’ and also ‘had a history of eating too quickly and storing food in his mouth.’
On the night of his death, the menu sheet reportedly showed that residents on a soft diet were offered beef stew or chicken paella. McPaul had selected the chicken paella. Fraser wrote: “The menu sheet, which showed what each resident was to eat that night clearly recorded that Mr McPaul was to receive chicken paella.” Even so, a different meal ended up in front of him.
Fraser said that, based ‘on the evidence, it was not clear how he came to be fed’ the steak pie, but the ruling made clear that the system in place was not good enough. Meals were transported from the kitchen on an unlabeled trolley, and staff were expected to identify and check dishes correctly.
The determination concluded: “This allows me to conclude that any system that was in place, which seemed to rely on individuals checking the menu card before distributing the meal, or relying on a care 34 worker to identify individual items of foodstuff that was not suitable, was not sufficiently robust.”
The home later introduced colour-coded plates to reflect dietary needs. No one was prosecuted, and the care home closed in 2020.