A housing association has been fined £100,000 after a vulnerable Cowdenbeath woman died after being fed a marshmallow by staff.
Shirley Breeze choked on the sweet treat in November 2019.
She then suffered two cardiac arrests and a seizure, which led to her being placed in an induced coma, and died two days later.
Kirkcaldy Sheriff Court heard Miss Breeze, 64, had severe learning disabilities but was being supported in her own flat in the Fife town.
Support workers did not receive adequate training on her special diet, resulting in her being given the unsuitable food.
Organisation admits breaching law
Ark Housing Association Ltd, a not-for-profit organisation which provides care, support, and housing for adults with complex needs, pled guilty to a health and safety at work breach committed between October 2018 and November 2019.
A spokesman said they took full responsibility for Miss Breeze’s death.
Miss Breeze, who had been cared for by the association since 2006, had been assessed as at risk of choking following an incident in June 2017.
She had been placed on a modified “soft” diet and had an eating and drinking plan in place along with a menu of suitable foods.
Ark failed to ensure staff were given adequate training on her diet or sufficiently familiar with the high-risk food groups, and the practice of changing or adding items to the menu planner contributed to unsuitable foods being given to Miss Breeze.
Crown says death is ‘entirely foreseeable’
The prosecutor stated it was entirely foreseeable that if support workers were not properly trained or instructed in the suitability of foods, they might offer foods which were unsuitable, and choking may result.
Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS) said: “The death of this vulnerable woman could have been prevented if suitable training and procedures had been in place.
“Ark Housing Association Ltd left service users at risk by failing to ensure staff had the relevant knowledge and training on modified diets for those in their care.
“This prosecution should highlight to other similar organisations that failure to fulfil their health and safety obligations can have tragic consequences and remind them they will be held accountable for their failings.”
Housing Association takes responsibility
A spokesperson for Ark Housing Association said: “This was a tragic accident which cost the life of someone we had looked after for 20 years.
“We immediately identified where we had failed Shirley and took full responsibility for this tragic accident.
“Over the past three years we have worked tirelessly to develop the most robust approach to training and support for our staff teams in this area.
“We hope those action, and our work with a number of other agencies in our sector can play an important role in preventing any repeat of this awful incident.”
