70-Year-Old Care Home Resident Choked to Death After Staff Gave Him the Wrong Meal: Report

The man had a history of choking and was on a soft diet when he was given the wrong meal

NEED TO KNOW

• A 70-year-old care home resident in Scotland died after being served the wrong meal, which caused him to choke to death
• Robert McPaul was on a soft foods diet and was given a steak pie with pastry that he choked on
• Sheriff Sheena Fraser found that the care home did not have an adequate system in place for serving the proper meals to its residents

A resident of a care home in Scotland died from being served the wrong meal.

Robert McPaul, 70, choked to death on pastry after caretakers served him the wrong meal at Sir Gabriel Wood’s Mariners’ Home in Greenock, Scotland, on March 30, 2018, per a fatal accident determination obtained by PEOPLE. The determination was made on March 17, 2026 by Sheriff Sheena Fraser.

Per the document, McPaul received a steak pie from caretakers at the home for dinner that was “not suitable for his specified dietary requirements." McPaul was on a Texture D diet, meaning he was only supposed to eat soft foods. The steak pie was also not the meal choice McPaul had selected, Fraser said.

The pastry from the pie lodged in McPaul’s trachea and caused him to choke to death, Fraser concluded.

“The primary cause of death was choking on food, with cerebrovascular disease being a potential contributing cause,” Fraser found.

McPaul was admitted to the Sir Gabriel Wood’s Mariners’ home on July 21, 2009. His medical history included cognitive impairment.

McPaul lived in the Korsakoff Unit of the building. The home provided specialty care for patients with Korsakoff syndrome, a chronic memory disorder caused by severe thiamine deficiency, per the Alzheimer’s Association.

At the time of his death, the document said, McPaul was “relatively immobile” and was taken to the dining room via wheelchair. He had several known struggles with eating, from difficulty swallowing to occasionally eating too fast. He could feed himself but sometimes needed to be fed or supervised.

Before this incident, McPaul had two choking incidents in his file, which led to him being placed on a soft foods diet. He also “had a history of eating too quickly and storing food in his mouth.”

McPaul was listed on the daily menu sheet as requiring a “soft diet.” The menu also listed each course’s options and whether they were suitable for certain diets. 

“On 30 March 2018 the two options noted on the menu sheet as being suitable for a soft diet were beef stew and chicken paella,” the document said. McPaul “selected chicken paella as his main course for dinner.” 

Steak pie was not an option for residents on a soft diet.

The staff of the care home would ask the resident which meal they wanted and mark it, and the kitchen would check that the meal suited the resident's diet.

“The menu sheet which showed what each resident was to eat that night clearly recorded that Mr McPaul was to receive chicken paella,” Fraser wrote.

“On the evidence, it was not clear how he came to be fed” the steak pie, she said, given that the kitchen staff knew it wasn’t suitable and McPaul had selected a different meal. One caretaker took the meal off the trolley, which was transported from the kitchen unlabeled alongside other meals, and a second served it to McPaul.

The caretaker “was supervising Mr McPaul as he ate his steak pie meal when she noticed him begin to cough, so she started to feed him to slow him down, but after one mouthful, he was clearly choking,” the document reads.

After McPaul began to choke, several staff members tried to help him. The ambulance crew that was called was unable to resuscitate him. 

Fraser wrote that the autopsy found material in McPaul’s trachea that “could have been pastry,” though it is not definitive what the blockage material was.

“On the evidence, it appears that [a caretaker] did not check the menu card to identify which meal was the correct meal for Mr McPaul before passing the steak pie dinner to [another carer] to serve to Mr McPaul,” the document said. “This allows me to conclude that any system that was in place, which seemed to rely on individuals checking the menu card before distributing the meal, or relying on a care 34 worker to identify individual items of foodstuff that was not suitable, was not sufficiently robust.”

The document said that the home failed to train employees or create a system that identified each resident’s diet and ensured they received meals consistent with that diet. 

Reasonable precautions that could have prevented McPaul’s death, Fraser wrote, included a system to identify each resident’s plate and meal restrictions or preferences through color coding, checking the dishes before they leave the kitchen, or a menu showing each patient’s selected meal and diet.

Per the determination, McPaul was born in Greenock, Scotland on Feb. 6, 1948. He worked in the Merchant Navy for 10 years after joining at 16. He worked in various management roles before retiring in 1988.

After McPaul's death, Fraser wrote, the home introduced color-coded plates to designate different dietary needs. “No individuals were prosecuted,” she said.

The document noted that the home closed in 2020 due to declining resources and failed efforts to increase occupancy. 

The home’s trustees are no longer involved in operating any care home.

Read the full article here