A prestigious Tayside care home has been fined £21,500 after a vulnerable resident drank a Covid cleaning product left in an unmarked bottle in his bathroom.
David Fyfe was 90 when he ingested disinfectant Steri Germ liquid, used in the early days of the pandemic, at Tigh-Na-Muirn care home in Monifieth.
Mr Fyfe, who had ischaemic heart disease and Alzheimer’s at the time of his death, died four days after consuming the ammonia-based cleaner on May 27 2020.
The liquid had been bought in bulk, diluted and decanted into smaller bottles as the care home fought against the killer coronavirus.
At an earlier hearing, company director Peter Philip admitted his firm, which employs 120 people, breached health and safety legislation and sentence was deferred to Wednesday.
Sheriff Jillian Martin-Brown imposed a fine of £30,000 on the company – which has an annual £3 million turnover – reduced to £20,000 in light of the early plea.
A victim surcharge of £1,500 was added.
Tragedy unfolds
The sheriff noted in the early days of the pandemic, there had been “confusion” around advice but a resilience plan at the time “stipulated isolated rooms would have their own cleaning kits, which would be kept in each room and not removed”.
Mr Fyfe was Covid-positive and isolating in his room and the Steri Germ was on the bathroom cabinet, as per his individual infection control plan.
At Dundee Sheriff Court today, Sheriff Jillian Martin-Brown fined Tigh-Na-Muirn Limited £20,000, after the company pled guilty to a breach of Health and Safety at Work Act 1974, following the death of a resident at a retirement home in Monifieth. https://t.co/QzQHyxTu2O
— Judges Scotland (@JudgesScotland) May 10, 2023
The sheriff said: “A carer checked on him at around 7:40 on May 27 and he appeared content, asking when breakfast would be served.
“No cleaning chemical was visible in the room at that time.
“At around 8:30 Mr Fyfe came to his door and was observed to be sweating profusely, having breathing difficulties and speaking with a hoarse voice.
“He stated he had chest pain. An ambulance was requested.
“At that time staff observed a paper cup with green residue on a table next to an unlabelled screw top spray bottle of cleaning sanitiser, still with the lid on.
“Paramedics transferred Mr Fyfe to hospital, where he gradually deteriorated until his death at midnight on 31 May 2020.
“The primary cause of death was acute tracheobronchitis and pneumonia, resulting from the ingestion of ammonium-based cleaning product.”
‘No financial gain’
The sheriff said it was unknown why Mr Fyfe’s Steri Germ bottle had no label as others did, although she noted they could be peeled off.
“Angus Council environmental health officers concluded that Mr Fyfe’s Covid plan did not consider any hazards to Mr Fyfe by storing chemicals in his room.
“They concluded the company had failed to adequately assess the risks posed to residents by the storage of Steri Germ in their rooms.”
Covid response boxes are now kept locked outside residents’ rooms and Steri Germ is no longer used, the court heard.
Sheriff Martin-Brown said “no financial gain was made, nor intended to be made” by Tigh-na-Muirn Ltd, a family business owned and operated by the Philip family since 1991.
“The breach occurred by omission.
“While, with the benefit of hindsight, Steri Germ ought not to have been stored in an accessible place in Mr Fyfe’s room, the management team did not have any cause to imagine that Mr Fyfe might deliberately or accidentally ingest the cleaning agent.
“Though he suffered from Alzheimer’s disease, his condition did not manifest itself in risky or erratic behaviour and he was able to undertake his own personal care independently, with minimal assistance.
“While the company fell short of the required standard, genuine efforts were being made in extremely challenging circumstances to respond to and react to a rapidly changing situation to keep residents and staff safe.
“The incident was an isolated one.
“The company has taken effective steps to remedy the deficiency.
“Documentation provided to the investigation by Angus Council indicated efforts by all concerned to comply with health and safety duties.
“ I accept the company had a responsible attitude to health and safety and an excellent safety record.
“It has no previous convictions.”
After the earlier hearing, a spokesperson for Tigh-Na-Muirn Ltd told The Courier: “We would like to offer our sincere condolences to the family.
“We have learned from this tragedy and taken all the necessary steps to ensure this never happens again.”
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