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A fatal accident inquiry has revealed that a care home resident died after being mistakenly served steak pie instead of the appropriate meal required for his dietary needs. Robert McPaul, aged 70, passed away on 30 March 2018 at Sir Gabriel Wood’s Mariners’ Home in Greenock. McPaul was on a textured diet, which meant he was only supposed to consume soft foods due to his health condition.
Sheriff Sheena Fraser ruled that the care home lacked an effective system to identify residents with special diet requirements and to ensure they received the correct meals. This failure contributed to McPaul being given a dish that was not suitable for his diet, leading to him choking on puff pastry from the steak pie and subsequently dying at the scene despite resuscitation attempts.
McPaul had lived at the care home since 2009, suffering from osteoarthritis and chronic oedema, and had a previous history of choking incidents. He had been placed on the textured diet in December 2017. On the day he died, the menu listed beef stew and chicken paella as suitable options for his diet, and while he selected the chicken paella, he was mistakenly served steak pie. The exact reason for the error was not clear, but it was attributed to human error by someone on duty at the time. Sheriff Fraser criticized the existing process, describing the reliance on a handwritten menu checked by a single carer as “not sufficiently robust” and a defect in the system.
Further findings noted that one of the staff members present during the incident was relatively new and had not yet received training in food and nutrition or the special dietary needs of residents. Meals were prepared by the head cook or assistant and then delivered on a trolley without a clear order or any plates marked with residents’ names. This lack of organization contributed to the confusion. After the incident, the care home introduced a system using different coloured plates for special diets, with these colors also indicated on meal menus to improve meal identification. The home, owned by the Sailors Society, closed in 2020, two years after McPaul’s death. This followed a decline in the number of beneficiaries and concerns over resources necessary for its upkeep. The last residents moved out in February 2021, and the trust is no longer involved in care home management
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