Operator HC-One has been fined £270,000 after a resident who suffered symptoms of Alzheimer’s Disease chewed chlorine tablets that led to his death.
Kirkcaldy Sheriff Court heard how on 4 August 2015 a delivery of cleaning products was made to Lomond Court Care Home in Glenrothes, Fife.
The products were left unattended in a corridor in an unsealed box, which also contained unwrapped chlorine tablets, about the size of a 10 pence piece, white and similar in appearance to mints.
Staff found the resident, 72-year-old James McConnell, distressed and in pain, close to the cleaning products. There was a tablet next to him and at least one in his mouth. Three of 200 tablets were missing.
Mr McDonnell sustained an injury to his mouth and tongue as well as vomiting. As a result, he developed aspiration pneumonia, complications of which led to his death.
An investigation by the Health and Safety Executive (HSE) found that prior to Mr McConnell’s death, the company had failed to assess the risk posed by several chemical products. They also failed to have an adequate system of work to manage deliveries of chemical products or to have an appropriate review procedure in place for the delivery arrangements of the chemical products for a period of two years.
HC-One pleaded guilty to breaching of the Health and Safety at Work Act 1974 and fined £270,000.
HSE inspector Garry Miller said: ‘This distressing incident confirms the need for anyone handling potentially harmful substances to be extra vigilant in ensuring that they are not left unattended in circumstances where vulnerable people in their care can gain access to them.
‘Suitable procedures need to be put in place and then regularly checked to ensure that they are being followed by everyone, not just for the use of such substances, but also for their delivery, storage and disposal.’
Paula Keys, HC-One chief operating officer, said: ‘We wholeheartedly apologise to Mr McConnell’s family, and whilst nothing can atone for their sad loss, we hope the outcome provided some sense of closure for them.
‘We have always been clear that lessons must be learned from this tragic event, as the health and safety of our residents is our absolute priority.
‘When it happened in August 2015, we immediately issued new delivery guidance to our Colleagues and suppliers so that potentially harmful products are securely stored on arrival at our homes, as well as insisting on ‘tamper proof’ containers for any potentially harmful products.
‘A comprehensive internal review was also completed and acted on, and the HSE has approved our new system for handling potentially harmful products.’