The 96-year-old resident of Cradlehall Care Home in Inverness was on a specialist diet of soft, moist and bite-sized food and her care plan stated that she should be closely supervised when eating and drinking.
However, on the afternoon of 11 June 2022 the unit in which she was accommodated was staffed by two agency carers who had responsibility for twelve residents
At about 5.45pm the woman was served a meal of macaroni and chips while sitting up in bed.
Her carer left to get a drink to accompany her meal but was then forced to deal with immediate issues with two other residents which required her to call for assistance from another unit.
As a result of this disruption the resident was left on her own for up to 20 minutes by the time the carer returned to her room with the drink.
The carer raised the alarm, and other staff came to assist. A paramedic arrived shortly afterwards and pronounced her dead.
At Inverness Sheriff Court on Monday (20 October 2025), HC-One Limited, who run the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974 and were over fined £1.8 million
Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the COPFS, said:
"The death of this vulnerable woman could have been prevented if a safe system of work were in place to ensure that on any occasion she ate a meal, she was subject to an appropriate level of supervision.
"HC-One Limited‘s failure left all residents at risk. This prosecution should reiterate the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.
"Our thoughts are with the family of the resident at what must be a difficult time for them."