Care home resident choked to death after being given wrong dinner

A care home resident choked to death after wrongly being given steak pie for his dinner, a fatal accident inquiry has found.

Robert McPaul died on 30 March 2018 while at Sir Gabriel Wood's Mariners' Home in Greenock. The 70-year-old was on a textured diet, meaning he should only have been eating soft food.

Sheriff Sheena Fraser ruled the care home did not have a suitable system in place that would let employees identify patients with a specific diet type, or to cross check that the patient with that diet received correct types of food.

Owners the Sailors Society decided to close the home in 2020, two years after the death.

McPaul had been a resident at the care home since 2009 and suffered from osteoarthritis and chronic oedema, while having a history of choking on his food.

He had been placed on a texture d diet the previous December.

On the day of his death, two dishes on the day's menu were listed as being suitable for a textured diet - beef stew and chicken paella.

McPaul chose the paella but was instead given steak pie and proceeded to choke on a piece of puff pastry.

Despite attempts to revive him and stop him choking, he died at the scene.

Sheriff Fraser said it remained unclear how he was served the wrong dish.

It was suggested that the wrong meal being given to him was simply down to "human error" from someone on the day.

Sheriff Fraser concluded the system for checking food was being served to the correct person was not satisfactory.

She wrote: "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."

One of the care workers with McPaul at the time of his death had worked at the home for less than three months, and had not yet been trained in food and nutrition - which included learning about different diets for residents there.

She was still shadowing a more senior member of staff when the choking incident occurred.

The FAI found that the head cook or her assistant would prepare individual meals, before they were taken to the dining room along with a copy of the handwritten menu.

However Sheriff Fraser noted that 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".

She added: "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."

The FAI heard that in the aftermath of the death the care home began placing different types of meals on different coloured plates, with the colour coding reflected on the meal menu sheet.

This helped to ensure different types of meals were more readily identifiable.

The FAI did not make any recommendations for the future, given the care home is now closed.

The closure followed a lengthy review of the home's future due to a sharp decline in the number of mariner beneficiaries, coupled with concerns over resources needed to maintain it.

The last residents left the home in February 2021 and the trustees are not involved in any other care homes.