THE family of a woman who choked and died at a Tullibody care home have aired their anger and grief after the operators of the home were fined £640,000.

A case against HC-One, the company that runs the Orchard Care Home, was prosecuted at Falkirk Sheriff Court recently for failing to ensure the health and safety of her and other residents.

Agnes Hughes, 65, known as Nanette, who was supposed to eat only soft, minced meals, had been given a doughnut as a late-morning snack.

Instructions that Nanette should only be fed "fork-mashable moist food" were adhered to correctly at meal times but had "somehow not been transposed" to staff handing out mid-morning refreshments, the court heard.

A sheriff who imposed the massive fine said it was a "significant" aggravating factor that less than three months before the tragedy, the home's owners had been fined £270,000 over a death in another of their Scottish homes.

In that case, a resident of Lomond Court in Glenrothes had chewed disinfectant tablets thinking they were mints.

The Orchard Care Home incident occurred at 11am on August 7, 2019, when a senior care assistant was providing residents with snacks from a tea trolley.

Jemma Eadie, prosecuting, told Falkirk Sheriff Court: "Another care assistant offered to help and asked Mrs Hughes if she would like a cup of tea and a piece of doughnut, and Mrs Hughes replied 'aye'.

"The care assistant gave her a piece of jam doughnut, then left the room."

As Mrs Hughes began to show signs of distress, someone – thought to be an off-duty home worker – sounded the emergency alarm and staff ran back into the room to find the "vulnerable" resident choking, and a plate on the floor with half a doughnut, and a bite taken out of it.

Ms Eadie said: "The care home manager and a staff nurse performed abdominal thrusts on Mrs Hughes while waiting for the emergency services."

Paramedics removed two pieces of food from her throat, but Mrs Hughes, from Tillicoultry, who suffered from vascular dementia, had a "do not resuscitate" notice in place, and died.

A post-mortem examination found food material deeply lodged and completely blocking her right bronchus, in a position not readily accessible during resuscitation outside hospital.

Mrs Hughes, a former knitwear factory worker, had been a resident at the home since 2017, following a severe stroke which left her unable to "mobilise or verbalise" and with severe cognitive impairment.

The court heard that according to a pathologist, choking while eating is a common risk factor among people with cerebral vascular disease and dementia.

A risk assessment carried out eight months before Mrs Hughes' death found she "ate food rapidly without chewing" and was "at high risk" of choking while eating.

Bread products were not permissible according to her diet plan, which also required she should have "maximum supervision".

Prior to her death, she had frequently been given sandwiches from the snack trolley, repeatedly putting her at risk.

Main meals at the home were prepared by the kitchen and labelled with each resident's name. However, the snack trolley did not have information on modified diets or food suitability.

Staff in charge of the trolley had also not had sufficient training on modified diets.

At Falkirk Sheriff Court, HC-One Limited pleaded guilty last Wednesday, January 12, to failing to ensure that residents at the home, in Lychgate Road, Tullibody, were not exposed to risks to their health and safety.

Peter Gray QC, defending, said Mrs Hughes' death had been "tragic", but though there had been failings in relation to carers' responsibilities for the distribution of snacks, there had not been "serious or systemic failures within the organisation".

He said HC-One Limited had since made changes to ensure the snack trolley had suitable food for all residents, and training had also taken place.

Sheriff Keith O'Mahony said the offence was not restricted to a single day, but had continued for eight months, and had not been restricted only to Mrs Hughes.

He said: "A situation had been allowed to develop whereby residents in a care home, already vulnerable, were exposed to the possibility of being given food, by way of snacks, which was unsuitable for any modified diet to which they might be subject.

"A choking risk had been identified and was being appropriately managed in respect of meals, but for some reason, what seems to be the rather obvious step of transposing that management plan onto snacks had not been taken.

"Mrs Hughes paid the price for those failures by HC-One.

"The consequence was tragic and Mrs Hughes died as a direct result."

He pointed out that "only a few months" before Mrs Hughes' death, HC-One Ltd had been convicted over the death in 2015 of 72-year-old James McConnell, from eating chlorine tablets at the firm's home in Glenrothes.

After the case was heard, Mrs Hughes' husband, retired joiner Tommy Hughes, 68, said: "My wife should not have died in this way.

"When she went into the care home, I thought she would be looked after.

"My dad had been in the Orchard Care Home previously, so I had great faith. My dad was treated well, but unknown to me, the home had changed ownership.

"When my wife went in, I was going across every night after work in my works van and I was there every tea time sitting with her, and the nurse said 'why are you coming in every evening'?

"I said: 'Because she's my wife'.

"They said: 'You said it, she's your wife, we're the carers, let us do our job, why don't you have a break?'

"Then when they cut down the visiting, two or three times afterwards when I went in I found her sitting in her bedroom by herself with her dinner in front of her."

He welcomed the fine, which he said had brought "closure".

He added: "Nanette would have been 68 at the end of this month.

"We got married in 1975, and I scattered her ashes on our 45th wedding anniversary, two and a half years ago.

"All I really wanted was for HC-One to come and say to me: 'We're sorry we did it, we should have listened to what you were telling us'.

"That's all I was looking for – satisfaction, and to realise that would save it happening to anybody else."

The couple had two sons, Michael, now 45, and Martin, 43.

Michael, who was also in court for the ruling, added: "This should never had happened to my mum."

In a statement issued by HC-One last week, James Tugendhat, the firm's chief executive officer, said: "First and foremost, we offer our heartfelt condolences and apologies to Mrs Hughes' family and loved ones.

"It was vitally important to us that lessons were learned when this occurred in 2019.

"Additional safeguards are now in place across all our homes to prevent a repeat of an accident like this, and Colleagues now complete additional and specific training focused on supporting Residents who have modified diets.

"The Care Inspectorate has recognised this work across our homes, as well as the very good care provided at The Orchard today.

"We are clear that this tragedy should never have happened, and we hope this judgement provides Mrs Hughes' family with some comfort and closure."