A company which runs care homes across England, has been fined more than £1.5 million after an elderly resident choked to death.
In April 2018, the 86-year-old man was admitted to Mill View care home in East Grinstead after a stay at East Surrey Hospital.
While at the hospital, a speech and language therapist identified he was at risk of choking and required a diet of soft foods.
Crawley Magistrates' Court found that staff at Mill View care home in East Grinstead, run by Care UK Community Partnerships Limited, gave unsafe and inappropriate food to the resident the entire time he was in their care.
It was found that staff did not understand how to prepare the correct food for the resident, the service failed to maintain accurate care records and the advice passed on from the hospital team was not fully incorporated into the resident's care plans and risk assessments.
A choking risk assessment was carried out on 30 April 2018 by a team leader, once the man had been admitted, which did not identify any choking risks.
His care plan was then reviewed at the care home on 16 May 2018 and it was amended to state he eats a normal diet and drinks normal fluids. No choking risks were identified.
Four days later, on 20 May, the resident was having lunch at the dining room table, when he started to choke and became unresponsive.
A post-mortem found he had eaten large pieces of meat and concluded the cause of death was choking on food.
Care UK Community Partnerships Limited was ordered to pay £1,527,170 in court on Thursday 9 June 2022.
It was also ordered to pay a £170 victim surcharge and £27,000 costs to the Care Quality Commission (CQC) which brought the prosecution.
Care Community Partnerships Limited pleaded guilty to failing to provide safe care and treatment to the resident, resulting in him being exposed to significant risk of harm which ultimately led to his death.
Hazel Roberts, CQC head of inspection for adult social care, said: "Our sympathies are with MC's family following his tragically needless death.
"He had the right to expect to be kept safe while living in Mill View and receiving care from the staff there, but in this case the provider, Care Community Partnerships Limited, failed in its legal duty to protect him from being exposed to significant harm.
"The majority of care providers do an excellent job. However, when a provider puts people in its care at risk of harm, we will take action to hold them to account and to protect people.
"I hope the outcome of this prosecution reminds care providers of their duty to assess and manage all risks to ensure people are kept safe".
Mill View care home provides accommodation and personal and nursing care for up to 70 people.
Care UK’s Regional Director, Georgina Stocker said: "We again offer our apologies and condolences to the family of Mr Craig.
"We pride ourselves on offering kind, safe care to all residents in our homes and are truly sorry that, on this occasion, our processes were not followed, allowing a team member to mistakenly serve Mr Craig an unsuitable meal.
"Following this incident in May 2018, we implemented a number of improvements across our homes to ensure we learn from this experience and minimise the chances of it happening again.
"These have included retraining everyone who might serve a meal, enhancing record keeping about people’s dietary requirements and scheduling different dining times, where needed, to give colleagues more time to support individual residents. This home was inspected by the Care Quality Commission in December last year and given a good rating."