Care home company fined £1.8M after resident's death

Elizabeth Campbell (known as Peggy) was a 96-year-old resident of Cradlehall Care Home in Inverness. She was on a specialist diet of soft, moist and bite-sized food and her care plan stated that she should be closely supervised when eating and drinking.

The Court heard that on 11 June 2022, the unit where Peggy resided was staffed by two agency carers who were responsible for twelve residents. At about 5.45pm, Peggy was served a meal of macaroni and chips while sitting up in bed.

One of the carers left to get a drink to accompany her meal but was then forced to deal with urgent issues with two other residents which required her to call for assistance from another unit. As a result of this disruption the resident was left on her own for up to 20 minutes by the time the carer returned to her room with the drink.

The carer raised the alarm, and other staff came to assist. A paramedic arrived shortly afterwards and the woman was pronounced dead.

An investigation by the Health and Safety Executive (HSE) concluded that Peggy’s death was caused by the fact the company had failed to ensure that all those working in the home had access to and were familiar with the care plans of its residents and that crucially Peggy had been left unsupervised while eating.  Following the investigation, HSE took action against the company, with improvements later being made to ensure there was a ‘skills mix’ during shifts – ensuring any agency staff were always assisted by regular employees, who were more aware of the needs of the home’s residents.

HC-One Limited, who run the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974. The company was fined £1.8 million at Inverness Sheriff Court on 20 October 2025.

HSE inspector Michelle Gillies said: “This incident was completely preventable had the company taken steps to ensure all of those working at the home knew about the needs of its residents.

“While no blame has been placed on any individual, the company’s failures in this case caused Peggy’s death.

“Sadly, this isn’t the first resident choking case HSE has had to investigate and we implore care homes companies to do all they can to protect their residents.

“Our thoughts remain with her family.”