Care home sentenced for failing that led to resident’s death

A care home has been fined £20,000 for health and safety failings which led to the death of a vulnerable 90-year-old man.

Tigh-Na-Muirn Limited, who run Tigh Na Muirn Residential Home in Dundee, pled guilty to a health and safety at work breach committed between 20 March and 1 June 2020. 

The procurator fiscal depute told Dundee Sheriff Court that on 27 May 2020 David Fyfe, a resident at Tigh Na Muirn, swallowed cleaning liquid and later died on 31 May 2020. 

Mr Fyfe had dementia and was unable to administer his own medication. 

Mr Fyfe tested positive for Covid-19 on 6 May 2020 and was placed in temporary isolation within his room in line with the COVID Resilience Plan the home had in place at that time. 

The infection control plan in place for him stated that cleaning products used in the room were to be stored on top of the bathroom cabinet. 

While clinical wipes would have been staffs’ preferred option, supply issues associated with the pandemic made this unfeasible and so the resilience plan was altered to include Sterigerm cleaning sanitiser. 

The home’s mental health manager stated that during his isolation period David Fyfe was more confused than normal, and she had contact with him daily to help him understand what was going on. 

On the final day of this isolation period on 27 May 2020 Mr Fyfe came to his door clutching his chest and stated that he had chest pain.  

Staff saw a paper cup with green residue on the table next to an unlabeled screw top spray bottle of cleaning sanitiser, still with the lid on. The paper cup had a green residue in the bottom which was the same colour as the cleaning sanitiser.  

Mr Fyfe was taken to hospital and following a gradual deterioration in his condition died on the 31st of May 2020 at midnight. 

The Angus Council investigation found that the infection control plan did not consider the hazard to David Fyfe by storing chemicals in his room. 

Following the incident locked boxes were placed outside resident’s rooms and contain everything a person with COVID or suspected COVID needs. The home now has access to wipes so the use of Sterigerm is no longer required. 

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the COPFS, said: 

"The death of David Fyfe could have been prevented if Tigh-Na-Muirn Limited had taken the reasonably practicable preventative measure of ensuring that residents were not exposed to the risk of hazardous cleaning chemicals. 

“Their failure to adequately assess the risks posed to residents by the storage of cleaning sanitiser in their rooms had fatal consequences. 

"This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”