​Comhairle fined £80k after death of care home resident

The council pled guilty to a charge under the Health and Safety at Work Act following the death of the 69-year-old man at St Brendan’s Care Home in Castlebay.

Allan MacLeod, who had been diagnosed with Dementia, had been a resident at the home – one of five operated by the council throughout the Western Isles – for around six months at the time of his death.

In the early hours of 9 March 2024, he had been able to leave his bedroom without the knowledge of staff and was only found around four hours after going missing. He died a short time later in hospital.

Mr MacLeod had been placed in the home in October 2023 to allow him to be nearer a relative who stayed on Barra.

In his first month at the home, staff observed him and determined patterns in his behaviour and how they could best assist him. He was able to go on regular road trips around the island with his family.

On 8 March, having been settled in bed around 9pm, hourly checks were carried out to ensure his wellbeing, but at 2am on 9 March, his bed was unoccupied, and he could not be accounted for after a search of the home.

To avoid being observed by staff, he had exited the home via the only door that was not alarmed, which was ten metres from his bedroom. Police Scotland were alerted and a search initiated.

Local Coastguard, RNLI and firefighters were called out to assist in the search and at around 6am, the coastguard helicopter detected a heat signature near the home on the patio of a residential property.

Mr MacLeod was found with facial injuries consistent with falling. He was transferred to hospital, but despite the efforts of medical staff, he died an hour later.

An investigation by the Health and Safety Executive determined that he had made several previous attempts to leave the home.

Any measures that staff had taken to mitigate this, by fitting an electronic tag to his clothing that indicated his whereabouts had been defeated by Mr Macleod having removed it.

A risk assessment carried out in December 2023 indicated that Mr MacLeod would remove a tag if he located it, therefore staff required to be vigilant to this behaviour.

It was only after his death that the home introduced a regime of half hourly checks on residents. Arrangements had already been made to install keypad entry systems on all doors, but this work had not been completed before Mr MacLeod’s death.

After a legal case was raised, the Comhairle pled guilty to breaching Sections 31 and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The council was fined £80,000 at Lochmaddy Sheriff Court on Wednesday.

HSE inspector Ashley Fallis said: “This was a tragic and preventable death.

“The council should have made sure the home had stronger measures in place with Mr MacLeod’s risks already known and assessed.

“Although changes have since been made, they came too late to prevent his death.”

The Comhairle have been approached for comment.