A health board in Scotland has been fined £40,000 by Inverness Sheriff Court after pleading guilty to a charge under Section 3 (1) of the Health and Safety at Work etc. Act 1974.
The Health and Safety Executive (HSE) investigated an incident in February 2014 where a patient died in hospital care.
The HSE reported that a 51 year old patient was admitted to a respiratory unit suffering from pneumonia and anaemia. The patient remained in hospital on various wards for the next 5 weeks.
The court heard that during this time, the patient was fed by a naso-gastric procedure due to the patient not being able to swallow.
A later patient review confirmed the need for the patient to be classed as “Nil by Mouth” (NIL). A sign was placed above the bed indicating this status. However, during a morning shift, an auxiliary nurse, unaware that the patient was NIL took a food order. The court was told that the patient did not indicate he was unable to eat normally.
The meal was delivered by a student nurse and the patient was left to eat his meal. 15 minutes later, the patient was found unresponsive with no pulse.
The HSE reported that the meal consisted of sausage and mashed potato and had been left for the patient to eat alone. Mashed potato was found by the side of the patient and in his breathing mask.
After the hearing, HSE Inspector Niall Miller said:
“The circumstances of this case were tragic and the death easily preventable. The failings demonstrate the need for effective communication and understanding in the health care environment and the need to appropriately manage the risks to patients with special requirements. “