Sheriff finds colour-coding system for meals could have prevented choking death of care home resident

About this case:

• Citation:
  [2026] FAI 12
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff Sheena M Fraser

Robert McPaul died at 5:57pm on 30 March 2018 while a resident of Sir Gabriel Wood’s Mariners’ Home, in consequence of him having served for 10 years in the Merchant Navy, which closed as a care home in 2021. It was noted that the trustees of the home were no longer involved in the operation of any other care home as of February 2021, when the last residents of the home departed.

The inquiry was conducted at Greenock Sheriff Court by Sheriff Sheena Fraser. The public interest was represented by Mr Ul-Hassan, procurator fiscal depute, with Ms McDonald appearing for the Trustees of Sir Gabriel Wood’s Mariners’ Home and Ms Blockley, advocate, for the care worker, BM, who served the meal to Mr McPaul.

Texture D diet

From 1968 to 2021, the home operated as a care home for retired seafarers and provided specialist care to those living with Alzheimer’s disease and Korsakoff’s syndrome as well as a separate facility for those capable of independent living. Following a sharp decline in the number of beneficiaries and added pressure from the pandemic, the home closed in February 2021.

Mr McPaul was admitted to the home in July 2009. Based on his history of choking and of storing food in his mouth, guidance given to the home in December 2017 stated he should receive a Texture D diet, comprising a pre-mashed dysphagia diet. On 30 March 2018, shortly after being given his evening meal, Mr McPaul began to choke, and despite the efforts of staff and ambulance crew to resuscitate him, he died at 5:57pm.

BM, Mr McPaul’s carer, had commenced employment at the home in January 2018 and at the time of his death was still in training. At the relevant time she had not yet attended the food and nutrition course that would have informed her as to what a Texture D diet involved. On 30 March 2018, the two options noted as being suitable for a soft diet were beef stew and chicken paella, with Mr McPaul having selected the latter option. It was not disputed that the pastry element of the steak pie that was served to Mr McPaul was not suitable for his diet.

It was noted that at the time of the incident there was no uniformly followed procedure to segregate different types of meals on the trolleys used to serve residents, however there was a meal sheet which clearly marked that Mr McPaul was to be given chicken paella. The only suggestion on the evidence as to why he was served the wrong meal was human error.

Not sufficiently robust

In her determination, Sheriff Fraser said of the Trustees’ submissions: “It was submitted I should make a finding that the cause or causes of any accident resulting in death was the entry of food from Mr McPaul’s mouth into his trachea causing him to choke. They invite me to make the finding that Mr McPaul took food from his own plate and put it in his mouth, at such a speed [BM] was unable to identify what it was he put in his mouth. I do not accept that evidence.”

Explaining her reasoning, she continued: “From the evidence that he choked as he ate a meal which was not prepared in a manner suitable for someone on a Texture D or E diet, a meal that included pastry which was a product which would only be considered suitable after an individual assessment of Mr McPaul (which had not taken place), and the evidence of the forensic pathologist (who said the foodstuff could have been pastry), I concluded that it was this meal, in particular the pastry, that caused him to choke. On that basis I find that the accident includes the provision to him of a meal which was inconsistent with his dietary requirements that cause him to choke.”

Considering defects in the home’s system of working, the sheriff said: “While the individual staff members were aware of Mr McPaul’s dietary requirements, it was not instantly identifiable to those in the dining room that the meal given to him, was not suitable. A system of work relying on a handwritten menu being checked by one individual carer before distributing meals is not sufficiently robust and I consider it to amount to a defect in the system of work. The system was changed after Mr McPaul’s death to have colour coded plates relating to each type of diet, so that the correct type of meal was instantly and clearly identifiable.”

She concluded on BM’s liability: “I was invited to find that because she was relatively new to her job, had shadowed someone who was herself relatively unclear about the requirements of a Texture D diet and having been instructed to feed Mr McPaul a specific meal handed to her by her senior, BM was not at fault for the death of Mr McPaul. This submission misses the purpose of this Inquiry. The purpose of an Inquiry under the Act, is not to attribute fault or blame in any way, rather to identify means by which similar deaths might be avoided.”

In light of the closure of the home in 2021, Sheriff Fraser made no recommendations regarding improvements and closed the inquiry by offering condolences to Mr McPaul’s friends and family.