Reasonable precautions at care home could have prevented choking death – inquiry

A care home could have taken “reasonable precautions” to prevent the death of a man who choked on food, a fatal accident inquiry has concluded.

Robert McPaul, 70, died while in the care of Sir Gabriel Wood’s Mariners’ Home in Greenock, Inverclyde, on March 30, 2018 after he was given food unsuitable for his diet.

Mr McPaul, who had lived at the home since 2009, had a history of choking and was restricted to a diet of soft food to prevent him from doing so.

The cause of the accident resulting in his death was found to be that Mr McPaul had been given a meal of steak pie, which was not prepared in accordance with his dietary requirements and was not the menu choice he had selected.

A fatal accident inquiry held at Greenock Sheriff Court determined there were several safeguards that could have been put in place to prevent his death.

Sheriff Sheena Fraser highlighted issues with the care home’s system of working, and said labelled, colour-coded plates and menus could have helped prevent the pensioner’s death.

Sheriff Fraser took expert evidence on the circumstances that led to his death, hearing from a number of parties involved at the inquiry.

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.

“The FAI followed a thorough and comprehensive investigation by the procurator fiscal who ensured that the full facts and circumstances of Mr McPaul’s death were presented in evidence.”

The care home closed in February 2021.

Unlike criminal proceedings, FAIs are inquisitorial in nature and do not seek to attribute blame. Instead, they aim to prevent similar deaths from occurring in future.