The determination makes detailed recommendations in relation to changes to the admissions process for new residents, and on policies and training for care home staff on the management of the risk of choking.
Mrs Anne Amos, aged 72, died in Pine Villa Nursing Home, Loanhead, Midlothian on 13 September 2021 after choking on food.
Unlike a criminal trial, an FAI seeks to establish the facts surrounding the death and is not a hearing which apportions blame.
The purpose of an inquiry is to establish the circumstances of the death and to consider what steps, if any, may be taken to prevent other deaths in similar circumstances.
Two recommendations for change in relation to Mansfield Care Ltd to highlight concerns about care home residents, and reduce the risks of swallowing problems and choking, were made in Sheriff Walls’s determination.
The Procurator Fiscal, who acts in the public interest, led expert evidence on the facts and circumstances of Mrs Amos’s death at the FAI in which other interested parties were represented.
Following the publication of the determination, Procurator Fiscal Andy Shanks, who leads on fatalities investigations for COPFS, said:
“The Sheriff's determination makes detailed recommendations for care home staff on the management of the risk of choking.
“The discretionary FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Mrs Amos’s death were presented in evidence. "
“My thoughts remain with her loved ones at this difficult time.”
Further information
For more information on Fatal Accident Inquiries se the Crown's guide