A fatal accident inquiry has concluded that a care home could have taken reasonable precautions to prevent the choking death of a resident who was given the wrong meal. Robert McPaul, 70, died at Sir Gabriel Wood’s Mariners’ Home in Greenock, Inverclyde, on 30 March 2018 after being served steak pie, which was not suitable for his soft-food diet.
Mr McPaul, who had lived at the home since 2009, had a history of choking and required a restricted diet. The inquiry at Greenock Sheriff Court heard that the meal he was given was not prepared according to his dietary requirements and was not the menu choice he had selected.
Sheriff Sheena Fraser identified shortcomings in the care home’s systems, stating that labelled, colour-coded plates and menus could have helped prevent the death. The sheriff took expert evidence from multiple parties involved in the case.
Debbie Carroll of the Crown Office and Procurator Fiscal said: “The death of Robert McPaul occurred in circumstances giving rise to significant public concern and as such a discretionary fatal accident inquiry was instructed. The sheriff’s determination is detailed and notes reasonable precautions that could have been taken to avoid Mr McPaul’s death.”
Unlike criminal proceedings, fatal accident inquiries are inquisitorial and do not seek to attribute blame, but aim to prevent similar deaths in the future.
