Mr McPaul, aged 70, died in Sir Gabriel Wood’s Mariners’ Home, Greenock on 30 March 2018 after choking on food that was not appropriate for his dietary requirements.
In her determination, Sheriff Sheena Fraser found that there were defects in the home’s system of working which contributed to Mr McPaul’s death.
She also found there was a reasonable precaution that could have been taken involving a system of labelled, colour coded plates, checked against a colour coded menu before leaving the kitchen and before service, could reasonably resulted in the death being avoided
The Procurator Fiscal, who acts in the public interest, led expert evidence on the facts and circumstances of Mr McPaul’s death at the FAI in which other interested parties were represented.
Following the publication of the determination, Debbie Carroll of the Crown Office and Procurator Fiscal Service, Scotland’s death investigation authority, said:
“The death of Robert McPaul occurred in circumstances giving rise to significant public concern and as such a discretionary Fatal Accident Inquiry was instructed.
“The sheriff’s determination is detailed and notes reasonable precautions that could have been taken to avoid Mr McPaul’s death.
“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Mr McPaul’s death were presented in evidence.”
For more information on Fatal Accident Inquiries, see the Crown’s guide