A care company has been handed a six-figure fine after its 'repeated failure' to act on recommendations led to a beloved Doncaster grandmother choking to death on a sandwich.
Four Seasons Homes Number 6 Ltd were fined £166,666 following the death of 'lovely' Margaret Streetly while she was a resident at Parklands Care Home in Thorne on March 3, 2014, at the age of 84.
Judge Paul Watson QC told Sheffield Crown Court that despite Mrs Streetly's care notes saying she posed a choking risk and should be on a pureed diet, on the night of her death she was given soup and cheese sandwiches to eat, and choked to death on of the sandwiches.
Mr Watson said the home, which is now owned by Parklands Care Services Ltd, missed several opportunities to refer her to a Speech and Language Therapy (SALT) team for an assessment as recommended, and had also failed to ensure that the choking risk was addressed despite it being known 14 months before her death.
The judge said he had taken into account that Four Seasons Homes Number 6 Ltd pleaded guilty to a charge relating to their failure to protect a person, other than an employee, from being exposed to a risk to their health and safety at the earliest opportunity.
He said: "I do not think that this is a case in which there has been deliberate or flagrant disregard of health and safety and so the case is not one of very high culpability.
"I do, however, find that the defendant fell far short of the appropriate standard by a) allowing the relevant breach to continue over a substantial period of time, b) repeated failure to act upon the recommendations that Mrs Streetly be referred to her GP and/or the SALT team c) failing to make appropriate changed when the risks were known and had been pointing out to the company."
Outlining the missed opportunities, Mr Watson said the home's first opportunity to act came in January 2013, when it was recorded in her notes that she needed to have her meat blended and she should be watched at meal times.
He added that in September 2013, Mrs Streetly was admitted to Doncaster Royal Infirmary with pneumonia and the doctor recommended a pureed diet and a referral to the SALT team.
Then during a choking risk assessment in December 2013, Mrs Streetly's swallowing difficulties were recorded again, but she was still not referred to the SALT team for assessment, Mr Watson said.
Speaking at a hearing on Monday, Paul Spencer, mitigating on behalf of Four Seasons Homes Number 6 Ltd said the care company acknowledged it had failed in a number of ways and added: "This death shouldn't have happened. It's tragic, and was preventable."
In handing the firm a £166,666 fine and ordering them to pay Doncaster Borough Council's costs of £16,160 within three months, Mr Watson said: "I cannot leave this case without once again repeating my genuine and heartfelt sympathies for the family of Mrs Streetly and those who were close to her.
"No financial penalty I impose can possibly equate to the tragic loss of a life or to the loss that they have suffered - nor is it intended to."
Speaking after the hearing, Peter Dale, Doncaster Council’s director of regeneration and environment, said: “We take all breaches of Health and Safety regulations extremely seriously and where necessary take formal legal action as in this case.
"This was a clear health and safety failure which resulted in the tragic untimely death of a vulnerable person and which all parties agree should never have happened.”
Robert Mitchell, a spokesman for Four Seasons Healthcare, said: "We would like to apologise again to Mrs Streetly’s family for the incident which occurred while she was in our care in March 2014 and which sadly resulted in her death.
"We deeply regret that the standard of care provided to her in relation to this incident fell short of what we expect of our homes and sufficient actions were not taken to prevent the risk of choking.
"The judge acknowledged that we had learned lessons from Mrs Streetly’s tragic death and that we had taken rigorous measures across all of our homes to reinforce the correct implementation of our organisation’s policies and procedures to safeguard residents.
"We continue to reinforce these measures in our homes, having introduced enhanced oversight by regional management that has fed through into programmes of training and development for staff in order to ensure high standards of care."