A care company is set to be fined over a health and safety breach which led to a beloved Doncaster grandmother choking to death on a sandwich.
'Lovely' Margaret Streetly was a resident at the Parklands Care Home in Eliison Street, Thorne when she died on March 3, 2014 at the age of 84.
At the time of Mrs Streetly's death, the care home was owned by Four Seasons Homes Number 6 Ltd, who later sold it in July 2015. It is now owned by Parklands Care Services Ltd.
Sheffield Crown Court heard how despite Mrs Streetly's care notes saying she posed a choking risk and should be on a pureed diet, on the night of her death she was given soup and a plate of sandwiches to eat, and subsequently choked on one of the sandwiches.
Representing Doncaster Metropolitan Borough Council, prosecutor, Ben Williams, told the court that concerns over Mrs Streetly's risk of choking had been raised and recorded in her notes on a number of occasions.
Despite this, Mr Williams said the home had missed several opportunities to refer her to a Speech and Language Therapy (SALT) team for an assessment as recommended, and had also failed to ensure she was kept on a pureed diet until such an assessment could be carried out.
He said: "The information is there. It has been properly recorded, it just has not, as the defendant accepts, been acted on."
Four Seasons Homes Number 6 Ltd pleaded guilty to a charge relating to their failure to protect a person, other than an employee, from being exposed to a risk to their health and safety during an earlier hearing held at Doncaster Magistrates' Court. The company is owned by Four Seasons Healthcare.
The missed opportunities
- Mr Williams said the home's first opportunity to act came in January 2013, when it was recorded in her notes that she needed to have her meat blended and she should be watched at meal times due to her dropping food when eating.
"Having assessed this difficulty, that was the first stage that a referral should have been made to the SALT team," said Mr Williams.
- In September 2013, Mrs Streetly was admitted to Doncaster Royal Infirmary for five nights with pneumonia, during which time she was given 'mashed-up food,' as a result of the choking difficulties she presented with, and the doctor recommended a referral to the SALT team.
Mr Willams said: "It is the prosecution's case that this significant stay in hospital with the information that was gathered by the doctors there should have been acted on.
"Where the defendant fell into error is in failing to update her care plan accordingly."
- During a choking risk assessment in December 2013, Mrs Streetly's swallowing difficulties were recorded again, but she was still not referred to the SALT team for assessment.
'This death shouldn't have happened'
Defending Four Seasons Homes Number 6 Ltd, Paul Spencer, said the care company acknowledged it had failed in a number of ways such as not acting on risk assessments, by not referring Mrs Streetly to the SALT team and by not ensuring she was on a pureed diet until she had been assessed by the SALT team.
"This death shouldn't have happened. It's tragic, and was preventable," said Mr Spencer.
He told the court that following Mrs Streetly's death, the care company had implemented a 'whole raft of changes' such as additional staff training and putting posters up in their care homes to remind staff and visitors to remind the home of the residents' nutritional needs.
"There have been no further choking events since this tragic incident. Looking at the fact there are 18,000 residents [in the company's 350 homes] cared for seven days a week, day in, day out, this may give Your Honour some confidence," added Mr Spencer.
Mitigating about the level of fine the company should receive, Mr Spencer said Four Seasons Homes was in debt and was having to fund 'significant interest payments every year'.
Judge Paul Watson QC adjourned the sentencing hearing until Thursday, when he will fine Four Seasons Homes Number 6 Ltd.
He told the court the fine will not be in excess of £250,000, and told Mrs Streetly's family members that they should not see whatever fine is passed as representative of the 'cost of a lost life'.
"Nothing I can say, by assessing the financial penalty, can compensate for the terrible loss Mrs Streetly's family have suffered," said Judge Watson.
He added: "Everything that has been said in this case about the preventability of Mrs Streetly's untimely death is absolutely right, she was entitled to expect care at a very high level and the failings were manifest."
'We can't bring her back'
Speaking after the hearing at Sheffield Crown Court on Monday, Margaret Streetly's daugther, Pauline Singleton, described her mother as a 'lovely lady' who had lived in Thorne for most of her life, after moving there from Stockton-on-Tees.
"It doesn't matter what they get fined, we can't bring her back. It shouldn't have happened," said Pauline. She added: "We wished she could have hung on until it was her time to go and we could have seen how long she lived for. She was strong like an ox, she was a right card."
Mrs Streetly's grandaughter, Michelle Singleton, said once the judgement had been passed on Thursday her grandmother would finally be able to rest in peace.