A care home has been ordered to pay £170,000 in fines and costs after a vulnerable resident choked to death on fish and chips during an entertainment evening.
Euxton Park Care Home, run by Four Seasons Health Care, was prosecuted after an investigation found that Rita Smith should only have been provided with pureed food as she had swallowing difficulties and was at risk of choking.
Preston Crown Court was told that the 75-year-old, who suffered from dementia and motor neurone disease, was admitted into Euxton Park Care Home in November 2010.
The home was made aware that Miss Smith had difficulty swallowing, needed pureed food on a teaspoon and supervision by a carer while eating.
However, just two weeks later, she was given fish and chips in a cone along with other residents while she was at a film and supper evening in the care home.
When a member of staff began clearing up the meals during the film, she noticed Miss Smith slumped in her chair.
A nurse attempted to resuscitate her but she was later pronounced dead.
A post-mortem examination found the primary cause of death was choking.
The HSE investigation into the incident found neither of the staff who organised the film and supper evening had been made aware that Miss Smith could not eat solid foods.
A specialist assessment carried out at the local hospital, recommending she be supervised at meals and prompted to slow down and swallow twice during each mouthful, had been provided to the care home but was not communicated to staff.
A care plan and risk assessment had also not be completed by Four Seasons for Miss Smith on her arrival at the home, which would have identified the need for a care worker to feed her pureed food during meal times.
Four Seasons Health Care, which runs 500 care homes in the UK, was fined £125,000 and ordered to £45,000 towards the cost of the prosecution.
Speaking after the hearing, HSE Inspector Shellie Bee said: “A vulnerable and elderly woman paid the price for their failures.
“Euxton Park Care Home was made aware of the risk of Miss Smith choking on un-pureed food when she arrived, but failed to act properly and as you would expect on this information.
“Sadly, she lost her life as a result.”