HC-One has been fined £270,000 after a resident at its Lomond Court Care Home in Fife died after eating chlorine cleaning tablets.
James McConnell, 72, died after swallowing the tablets that had been left unattended in an unsealed box on August 4, 2015.
HSE inspector Garry Miller said: “This distressing incident confirms the need for anyone handling potentially harmful substances to be extra vigilant in ensuring that they are not left unattended in circumstances where vulnerable people in their care can gain access to them.
“Suitable procedures need to be put in place and then regularly checked to ensure that they are being followed by everyone, not just for the use of such substances, but also for their delivery, storage and disposal.”
Mr McDonnell sustained an injury to his mouth and tongue as well as vomiting after swallowing the tablets. He then developed aspiration pneumonia, the complications of which led to his death.
Paula Keys, Chief Operating Officer, HC-One, said: “We wholeheartedly apologise to Mr McConnell’s family, and whilst nothing can atone for their sad loss, we hope today provides some sense of closure for them.
“We have always been clear that lessons must be learned from this tragic event, as the health and safety of our residents is our absolute priority.
“When it happened in August 2015, we immediately issued new delivery guidance to our colleagues and suppliers so that potentially harmful products are securely stored on arrival at our homes, as well as insisting on ‘tamper proof’ containers for any potentially harmful products.
“A comprehensive internal review was also completed and acted on, and the HSE has approved our new system for handling potentially harmful products.”