A housing association has been fined £100,000 for health and safety failings which led to the death of a vulnerable 64-year-old woman in its care.
Shirley Breeze choked after her support worker gave her a marshmallow that was not suitable for her dietary needs.
She then suffered two cardiac arrests and a seizure which led to her being placed in an induced coma.
She died on December 2, 2019.
Ark Housing Association Ltd, a not-for-profit organisation which provides care and housing for adults with complex needs, was in charge of Miss Breeze’s care.
The Crown Office said Ark pled guilty to a health and safety at work breach committed between October 2018 and November 2019 at a hearing at Kirkcaldy Sheriff Court on Thursday.
Miss Breeze was a service user of Ark since October 2006 and was provided with support to live independently in her own flat in Cowdenbeath, Fife.
She had severe learning disabilities and received 24/7 care.
Miss Breeze had been assessed as “at risk of choking” following an incident in June 2017.
This prosecution should highlight to other similar organisations that failure to fulfil their health and safety obligations can have tragic consequences— Debbie Carroll, Crown Office
She had been placed on a modified “soft diet” and had an eating and drinking plan in place along with a menu of suitable foods.
Prosecutors said Ark failed to ensure staff were given adequate training on her diet or were sufficiently familiar with the high-risk food groups and the practice of changing or adding items to the menu planner, which contributed to unsuitable foods being given to Miss Breeze.
They said it was entirely foreseeable that if support workers were not properly trained or instructed in the suitability of foods, they might offer foods which were unsuitable, and choking may result.
Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (, said: “The death of this vulnerable woman could have been prevented if suitable training and procedures had been in place.
“Ark Housing Association Ltd left service users at risk by failing to ensure staff had the relevant knowledge and training on modified diets for those in their care.
“This prosecution should highlight to other similar organisations that failure to fulfil their health and safety obligations can have tragic consequences and remind them they will be held accountable for their failings.”
A spokesperson for Ark Housing Association said: “This was a tragic accident which cost the life of someone we had looked after for 20 years.
“We immediately identified where we had failed Shirley and took full responsibility for this tragic accident.
“Over the past three years we have worked tirelessly to develop the most robust approach to training and support for our staff teams in this area.
“We hope those actions, and our work with a number of other agencies in our sector, can play an important role in preventing any repeat of this awful incident.”
