Full Breakdown
Fatal Accident Inquiry Reveals Care Home Oversight in Resident's Death
3/26/2026, 12:10:31 AM
Overview of the Incident
Robert McPaul, a 70-year-old resident of Sir Gabriel Wood's Mariners' Home in Greenock, died on March 30, 2018, after choking on a steak pie that was unsuitable for his dietary needs. McPaul had been on a textured diet, requiring soft food due to a history of choking, and had selected chicken paella for his dinner. The fatal accident inquiry (FAI) revealed that the care home lacked a robust system to ensure residents received appropriate meals.
Findings of the Inquiry
Sheriff Sheena Fraser, who presided over the inquiry, concluded that the care home did not have adequate measures in place to identify residents' dietary requirements. The inquiry highlighted that the system relied on a handwritten menu checked by a single carer, which was deemed insufficient. The head cook or assistant prepared meals without a clear system for identifying which meal belonged to which resident, as there were no names on the plates.
The inquiry found that McPaul's death could have been prevented had reasonable precautions been taken, such as implementing a color-coded system for meal identification. Following the incident, the care home began using different colored plates to distinguish between meal types, reflecting the dietary requirements of residents.
Background and Context
McPaul had been a resident at the care home since 2009 and had suffered from osteoarthritis and chronic edema. He had been placed on a textured diet in December 2017 due to his choking history. The care home closed in February 2021, two years after McPaul's death, due to a decline in the number of residents and concerns over resources.
Official Statements & Responses
Debbie Carroll of the Crown Office and Procurator Fiscal stated that McPaul's death raised significant public concern, prompting the inquiry. She noted that the sheriff's determination included recommendations for safeguards that could have prevented the incident. Sheriff Fraser emphasized the need for a more reliable system to ensure that residents received the correct meals according to their dietary needs.
Criticism & Opposition
While the inquiry did not attribute blame, it underscored the care home's failure to implement necessary precautions. Critics have pointed out that the reliance on a single carer for meal distribution, particularly one who was relatively inexperienced, contributed to the tragic outcome.
Verbatim Quotes
“There was no evidence to suggest that the steak pie dinner was one which was suitable for someone on such a diet, and it was not the meal selected by Mr McPaul for his dinner that night.” — Sheriff Sheena Fraser
“A system of work relying on a handwritten menu being checked by one individual carer before distributing meals is not sufficiently robust and I consider it to amount to a defect in the system of work.” — Sheriff Sheena Fraser
What's Next
The care home is now closed, and the trustees are not involved in any other care facilities. The inquiry did not issue recommendations for future practices, as the facility is no longer operational.
