Care Home Fined After Resident Choked Following Unsafe Texture Modified Meal

Brief Summary

A care home was fined after a resident with well documented dysphagia and high risk of choking died following lunch when food was not prepared to his required texture modified diet standard. The case highlights how training is not enough if the system for preparing and serving modified meals is not consistently reliable.

What Was The Incident?

On 25 May 2023, Thomas Telford, aged 86, choked during lunch at Riverside Healthcare Centre, Selkirk. He had dysphagia identified from November 2019 and required a Level 5 diet under the IDDSI framework, meaning minced and moist food prepared to defined dimensions. During the incident, the beef served to him was not prepared in accordance with his Level 5 requirements.

What Was The Outcome?

Riverside Care Limited pleaded guilty on 3 March 2026 to breaching Section 2(1) of the Health and Safety at Work etc Act 1974. The company was fined £16,000 at Selkirk Sheriff Court.

What Lessons Can Be Learnt?

Make the modified diet system robust and fail safe. Having a broad system and staff training is not sufficient if the day to day process cannot be relied on to produce and serve the correct texture modified food every time.

Treat documented swallowing needs as operational requirements. Where a resident is assessed as needing a specific IDDSI level and has clear swallowing and choking risks, those requirements must drive meal preparation and serving decisions without deviation.

Use supervision and mealtime controls, but do not rely on them alone. The resident required supervision due to risk factors such as overfilling his mouth and eating quickly. Supervising dining helps, but it cannot compensate for food that is not prepared to the required specification.

Ensure end to end control from preparation to plate. The investigation found a failure in the system of work for preparing and serving modified meals. Controls must cover the whole chain, including how modified meals are made, verified, and delivered to the right person.

Audit performance at each mealtime and correct process breaks. This was not described as a lack of knowledge, but as a system failure that led to unsafe food being served. Care providers should check that procedures work consistently in practice at every mealtime without exception.

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