• Resident died after being served food that did not meet his documented swallowing requirements.
• HSE investigation found a failure in the system of work for preparing and serving modified meals.
• Thomas Telford had a well-documented history of dysphagia and was at high risk of choking.

A Selkirk care company has been fined after a resident choked to death on food that had not been prepared in accordance with his dietary requirements.

Selkirk Sheriff Court heard that on 25 May 2023, Thomas Telford, known as Barry, aged 86, choked during lunch at Riverside Healthcare Centre, Bridge Street, Selkirk.  Mr Telford had been a resident at the home since 9 May 2023, having been admitted directly from Kelso Community Hospital. He had a complex medical and a well-documented history of dysphagia — difficulty swallowing — that had been identified as far back as November 2019.

Mr Telford had been assessed as requiring a Level 5 (minced and moist) diet under the International Dysphagia Diet Standardisation Initiative (IDDSI), meaning all food should be minced into small moist pieces no greater than 15mm in length and 4mm wide. His care plan also required that he be supervised at mealtimes due to his tendency to overfill his mouth and eat quickly, and he had been identified as being at high risk of choking.

At lunchtime on 25 May 2023, Mr Telford was served a meal of beef, mashed potato and cabbage. The beef served to him had not been prepared in accordance with his Level 5 dietary requirements. A carer supervising the dining room noticed his lips turning blue and immediately raised the alarm. Backslaps and abdominal thrusts were administered, and an ambulance was called. He was pronounced dead at Borders General Hospital at 14:00 hours.

An investigation by the Health and Safety Executive (HSE) found that Riverside Care Limited had failed to ensure a sufficiently robust system of work for the preparation and serving of texture-modified meals. Whilst the home operated a broadly suitable system of serving either normal or modified meals, and staff had received training on dysphagia and the IDDSI framework, that system had failed on the day in question. As a result, Mr Telford was served food that was not safe for him to consume.

Employers providing care to individuals with swallowing difficulties must ensure that systems for preparing and serving texture-modified diets are sufficiently robust to guarantee that only appropriate food is served to those who require it, at every mealtime without exception.

HSE provides extensive guidance intended to help those providing and managing care homes – to give them a better understanding of the real risks and how to manage them effectively.

On Tuesday 3 March 2026, Riverside Care Limited, of Bridge Street, Selkirk, pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc. Act 1974. The company was fined £16,000 at Selkirk Sheriff Court.

After the hearing, HSE Inspector Robbie Morrison, said:

“Mr Telford’s need for a texture-modified diet was well documented and well known to those caring for him. He had a history of dysphagia and had been clearly identified as being at high risk of choking.

“Employers have a duty to ensure that the systems they put in place to protect the people in their care are robust enough to work consistently and without fail. In this case, that system was not sufficiently robust, and the consequences were fatal.

“This was a tragic and entirely preventable death. We hope this case serves as a reminder to all care providers of their responsibility to ensure that residents with complex dietary needs receive only food that is safe for them.”

Further information:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. Guidance on health and safety in care homes can be found here: Health and safety in care homes – HSE
5. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so.  The sentencing guidelines for health and safety offences can be found here.

• Resident, 96, choked on food after being left on her own.
• Care workers did not know about her care plan.
• Company only made improvements following her death.

A care home company has been fined over £1.8 million after a resident choked on a piece of food while consuming her evening meal alone in her room.

Elizabeth Campbell (known as Peggy) was a 96-year-old resident of Cradlehall Care Home in Inverness. She was on a specialist diet of soft, moist and bite-sized food and her care plan stated that she should be closely supervised when eating and drinking.

The Court heard that on 11 June 2022, the unit where Peggy resided was staffed by two agency carers who were responsible for twelve residents. At about 5.45pm, Peggy was served a meal of macaroni and chips while sitting up in bed.

One of the carers left to get a drink to accompany her meal but was then forced to deal with urgent issues with two other residents which required her to call for assistance from another unit. As a result of this disruption the resident was left on her own for up to 20 minutes by the time the carer returned to her room with the drink.

The carer raised the alarm, and other staff came to assist. A paramedic arrived shortly afterwards and the woman was pronounced dead.

An investigation by the Health and Safety Executive (HSE) concluded that Peggy’s death was caused by the fact the company had failed to ensure that all those working in the home had access to and were familiar with the care plans of its residents and that crucially Peggy had been left unsupervised while eating.  Following the investigation, HSE took action against the company, with improvements later being made to ensure there was a ‘skills mix’ during shifts – ensuring any agency staff were always assisted by regular employees, who were more aware of the needs of the home’s residents.

HC-One Limited, who run the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974. The company was fined £1.8 million at Inverness Sheriff Court on 20 October 2025.

HSE inspector Michelle Gillies said: “This incident was completely preventable had the company taken steps to ensure all of those working at the home knew about the needs of its residents.

“While no blame has been placed on any individual, the company’s failures in this case caused Peggy’s death.

“Sadly, this isn’t the first resident choking case HSE has had to investigate and we implore care homes companies to do all they can to protect their residents.

“Our thoughts remain with her family.”

Further information:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so.  The sentencing guidelines for health and safety offences in Scotland can be found here.

• Man was able to leave care home undetected in early hours of morning.
• Search involved police, coastguard and firefighters.
• Doors at the home were not alarmed or protected.

A local authority has been fined after the death of a patient who went missing from a care home on the Isle of Barra.

Western Isles Council pled guilty to a charge under the Health and Safety at Work Act following the death of a 69-year-old man at St Brendan’s Care Home in Castlebay.

Allan MacLeod, who had been diagnosed with Dementia, had been a resident at the home – one of five operated by the council throughout the Western Isles – for around six months at the time of his death. In the early hours of 9 March 2024, he had been able to leave his bedroom without the knowledge of staff and was only found around four hours after going missing. He died a short time later in hospital.

Mr MacLeod had been placed in the home in October 2023 to allow him to be nearer a relative who stayed on Barra. In his first month at the home, staff observed him and determined patterns in his behaviour and how they could best assist him. He was able to go on regular road trips around the island with his family.

On 8 March, having been settled in bed around 9pm, hourly checks were carried out to ensure his wellbeing, but at 2am on 9 March, his bed was unoccupied, and he could not be accounted for after a search of the home.

To avoid being observed by staff, he had exited the home via the only door that was not alarmed and was ten metres from his bedroom. Police Scotland were alerted and a search initiated.

Local Coastguard, RNLI and firefighters were called out to assist in the search and at around 6am, the Coastguard helicopter detected a heat signature near the home on the patio of a residential property.

Mr MacLeod was found with facial injuries consistent with falling. He was transferred to hospital, but despite the efforts of medical staff, he died an hour later.

An investigation by the Health and Safety Executive (HSE) determined that he had made several previous attempts to leave the home. Any measures that staff had taken to mitigate this, by fitting an electronic tag to his clothing that indicated his whereabouts had been defeated by Mr Macleod having removed it.

A risk assessment carried out in December 2023 indicated that Mr MacLeod would remove a tag if he located it, therefore staff required to be vigilant to this behaviour. It was only after his death that the home introduced a regime of half hourly checks on residents. Arrangements had already been made to install keypad entry systems on all doors, but this work had not been completed before Mr MacLeod’s death.

Western Isles Council, of Sandwick Road, Stornoway, pleaded guilty to breaching Sections 31 and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The council was fined £80,000 at Lochmaddy Sheriff Court on 6 August 2025.

HSE inspector Ashley Fallis said: “This was a tragic and preventable death.

“The council should have made sure the home had stronger measures in place with Mr MacLeod’s risks already known and assessed.

“Although changes have since been made, they came too late to prevent his death.”

Further information:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so.  The sentencing guidelines for health and safety offences in Scotland can be found here.

• Vulnerable man walked more than 300 steps from his room to a carpark.
• Care home staff did not notice he had left and falsified records.
• HSE guidance is available on vulnerable residents

A care home provider has been fined more than £50,000 after an elderly patient died in the early hours of Boxing Day in 2022.

Hugh Kearins, 77, had managed to leave the Chester Park Care Home in Glasgow via a series of stairways and fire doors. An inspector from the Health and Safety Executive (HSE) counted 320 steps from Mr Kearins’ room to the care home’s car park just off Lambhill Street, where his body was found at around 7am.

Mr Kearins, who had dementia, had been living in a room within the Clyde Unit of the home since 2012. As part of its investigation, HSE made enquiries regarding the use of an internal fire door and was unable to obtain corroborated evidence of who was last to use the door prior to Mr Kearins, who is thought to have exited through it just before 1am. The same door was closed about an hour later by an unknown member of staff carrying out routine checks.

It was confirmed by the care home manager that once the door was noted to be insecure, the member of staff should have initiated a head count of all of the residents to ensure their safety. However, this was not carried out.

The HSE investigation found the company had failed to have a safe system of work in place. Records held by the company in relation to Mr Kearins, extensively noted the clear risk that he might abscond or ‘wander’. It was part of his care plan that he be checked or monitored every hour.

HSE guidance states that the security of doors and gates should be considered where assessment identifies that specific residents leaving the premises will present a significant risk to their safety. It adds that in some instances it may be appropriate to consider devices that alert staff of their location and whether they are at risk of harm.

A senior care assistant and a care assistant who had responsibility for Mr Kearins’ care were also found to have falsified records, stating that they had performed tasks involving him at a time when he was in fact no longer in the home. Both were unaware he was no longer in his room until news of his death became known following the discovery of his body in the car park.

The management failures in respect of the alarm door reactivation were not causative of Mr Kearins’ death and would likely not have even come to light but for four individual errors:

• The unidentified member of staff who closed the internal fire door without further action;
• The fire alarm for the internal fire door which had been deactivated
• The unidentified member of staff who left the unalarmed external fire door insecure; and
• The actions of both the senior care assistant and the care assistant.

Oakminster Healthcare Limited, of Lambhill Street, Glasgow, pleaded guilty to breaching Sections 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The company was fined £53,750.

HM Inspector Amna Shah said: “This incident was completely avoidable.

“It is hugely concerning that a vulnerable man was able to walk so far and through so many doors without being noticed.

“We counted he had walked more than 300 steps.

“The fact this incident happened at Christmas time makes it all the more tragic.

“We will always take action against those who fail in their responsibilities.”

Further information:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so.  The sentencing guidelines for health and safety offences in Scotland can be found here.
5. HSE guidance about health and safety in care homes is available.
6. Both carers were subsequently dismissed from their employment following disciplinary interviews a few days later. They are now subject to investigation by the Scottish Social Services Council.