A Kinross-shire care worker has been cleared of contributing to a man’s death after he choked on a piece of toast.
The man died in October 2022, while eating unsupervised at the An Cala care service run by Hillcrest Futures in Kinnesswood.
The Scottish Social Services Council (SSSC) – the watchdog for registered care workers – launched an investigation into the actions of Angel Papierowska, one of two workers on duty at the time of the man’s death.
It investigated allegations that Ms Papierowska had failed to supervise the man, referred to only as AA, while he ate – contrary to his care plan – which it found was proved.
It also alleged that as a result of this, she contributed to AA choking on his food and consequently his death, which was not proved.
Speaking to The Courier after the hearing, Ms Papierowska, 24, said she had been left with PTSD after the incident.
Man found to have choked to death after eating toast
A report into the SSSC hearing detailed the role of Ms Papierowska and her colleague, named only as ZZ, on the day that the man died.
It said Ms Papierowska made the man toast and peanut butter after he said he did not wish to eat the meal prepared that evening.
The man moved to a room where he would often eat his meals away from the other residents – due to his behaviour towards other staff and service users – and Ms Papierowska took the toast there.
After five minutes, her colleague ZZ checked on the resident and found him to have choked to death.
The SSSC panel heard evidence from several people, including ZZ, who said she felt the service had been short-staffed as there were “usually three staff on the evening shift”.
It was revealed there had been another incident that day where the man had also choked on food at lunchtime.
Kinross care worker ‘could not have foreseen choking risk’
The panel found there had been a lack of proper handover about the earlier choking incident between staff working at lunchtime and those on duty later in the day.
And while the SSSC determined that Ms Papierowska – who did not attend the hearing – had failed to comply with AA’s outcome plan, it found was not aware of any risk that he could choke.
The report said: “That is not to say that there was no risk in leaving AA unsupervised, but the risk of the tragic outcome that occurred was not a risk you would have been expected to have foreseen.”
The SSSC also said that it should have been down to managers to source a third member of staff to work, and not Ms Papierowska.
The panel further concluded that the man may have died even if he had been supervised.
It said: “While it is possible that the presence of a staff member at the start of the choking event would have resulted in an earlier intervention, and a chance of a better outcome, the panel was not willing to conclude that this would have been successful in preventing his death.
“It is not known how long AA had been choking when he was found, or whether the food was capable of being dislodged by you or ZZ.
“It is not known why AA had two choking incidents.
“It is not known whether his cardiac arrest would have been avoided if the blockage had been cleared more quickly, or whether the earlier choking incident had any role to play in how his body responded to the second event.”
The SSSC said Ms Papierowska’s misconduct was not serious enough to require suspension or removal from the register.
Instead, a warning has been imposed on Ms Papierowska’s record for six months, along with some conditions.
It has not been confirmed if ZZ is facing a separate probe.
‘I have gone through a range of emotions about this’
Speaking to The Courier after details of the hearing were published, Ms Papierowska said: “This tragic incident happened as a result of poor staffing levels in the home and due to a lack of proper management guidance.
“Understaffing is a big problem with only one or two people on shift when there should be three.
“I consider a big part of the blame lies with Hillcrest themselves and the management in the home.
“I have gone through a range of emotions about this.
“I had no desire to return to work at the home and am currently not working.
“I have been suffering PTSD as a result of what happened.”
A spokesperson for Hillcrest Futures said: “Following the incident that occurred in 2022, we immediately conducted a comprehensive and thorough investigation.
“As the people who use our services are at the core of everything we do, and their wellbeing of the utmost priority, we have implemented all recommendations arising from the review.
“The staff member involved is also no longer with the company.”
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