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Care Home Fined after Elderly Resident Choked to Death

A care home has been fined after an incident in which an elderly resident choked to death on food that had not been cut into appropriate sized pieces.


Mrs Margaret Humphreys was a resident at Marlborough House in Fleet, Hampshire at the time of the incident. Mrs Humphreys’ family had arranged for her to stay at the care home and had provided staff with ‘clear’ instructions explaining that her food needed to be cut into very small pieces so that she would not choke. Her family had provided the instructions both verbally and in the form of a laminated card.

HSE Investigation

Health and Safety Executive (HSE) inspectors found that staff at the care home had served Mrs Humphreys with a meal of uncut meatballs.

The HSE investigation also confirmed that staff had failed to carry out a suitable assessment of Mrs Humphreys prior to her admission to the home. This assessment would have identified the danger of Mrs Humphreys choking on uncut food.


After failing to discharge the duty imposed upon them by Section 3(1) of the Health and Safety at Work etc Act 1974, Craysell Limited, of Hoppingwood Farm, Robin Hood Way, London, was fined £80,000. The company was also ordered to pay costs of £19,631.

HSE inspector Andrew Johnson said after the hearing:

“This was a completely avoidable tragedy. The home was informed in the clearest terms that if Mrs Humphreys was presented with food that was uncut, she would choke, this crucial information was ignored.

“Had Marlborough House properly assessed Mrs Humphreys, the risk of her choking would have been identified and measures put in place to control this risk.

“This case sends out a clear message to the care home sector, illustrating the importance of listening to residents’ family’s instructions and to also properly assess and provide the same standard of care to respite residents as they would to permanent residents. This tragic case must act as a reminder of the importance of properly assessing new residents and that vital information must be properly communicated to care staff.”

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Source: Health & Safety Executive

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