Monifieth care home fined £20k after resident, 90, died from ingesting sanitiser during Covid lockdown

A retirement home has been fined £20,000 after health and safety breaches led to the death of a 90-year-old man during the coronavirus lockdown.

David Fyfe died at Tigh-Na-Muirn home in the Monifieth near Dundee after ingesting Sterigerm cleaning sanitiser on May 27, 2020.

The ammonia-based cleaning agent had been intentionally left in his room at the top of his en-suite bathroom cabinet by staff while he was isolating with Covid.

At Dundee Sheriff Court this week, Sheriff Jillian Martin-Brown issued the fine after the private limited company pled guilty to a breach of Health and Safety at Work Act 1974.

The court heard how the family-run business has been owned and operated by the Philip family since 1991.

Mr Philip is a director and works full time with his daughter in running the home with the support of a General Manager and have 120 employees.

Mr Fyfe was isolating in his room as a result of testing positive for Covid when the incident occurred.

Mr Fyfe had dementia and was unable to administer his own medication.

Policy during the pandemic was for each isolating room to have its own cleaning products.

A team decision was taken to use Sterigerm and store it within Covid positive residents’ rooms as a result of supply issues with clinical wipes during the pandemic.

Mr Fyfe’s room was cleaned on May 26, 2020 and cleaning products were stored towards the back of the top of the bathroom cabinet.

A carer checked on him at around 7.40am on May 27 and, the court heard, he appeared content and asked when breakfast would be served.

No cleaning chemical was visible in the room at that time.

At around 8.30am Mr Fyfe came to his door and was observed to be sweating profusely, having breathing difficulties, speaking with a hoarse voice and stated he had chest pain.

An ambulance was called and, at this time, staff saw a paper cup with green residue on a table next to an unlabelled screw top spray bottle of cleaning sanitiser which still had the lid on.

When the ambulance arrived at the home, paramedics transferred Mr Fyfe to Ninewells Hospital where his health deteriorated further.

He later died on May 31, 2020.

Doctors determined that the cause of death was acute tracheobronchitis and pneumonia, resulting from the ingestion of ammonium-based cleaning product.

Ischaemic heart disease and Alzheimer’s disease were listed as contributory factors.

The court heard how it was unknown why the bottle of Sterigerm had no label as the company procedure was for every bottle to be labelled on both sides with instructions for use.

The bottles in other isolation rooms had labels, although it was noted that these could be pulled off.

A probe by Angus Council Environmental Health officers concluded that the company had failed to adequately assess the risks posed to residents by the storage of Sterigerm in their rooms.

Following the incident, all Covid response kits are kept locked outside residents’ rooms.

The home also now has access to wipes so the use of Sterigerm is no longer required.

Following the sentencing, Sheriff Martin-Brown said: “I have taken into account what has been said on behalf of the company by senior counsel; the written plea in mitigation; the financial information provided; the agreed narrative; and the crown’s written submissions.

“Ultimately, after careful consideration, I have determined an appropriate level of fine. I will set out the level of fine that I am imposing first and then I will explain the reasons for my decision.”

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the COPFS, said: “The death of David Fyfe could have been prevented if Tigh-Na-Muirn Limited had taken the reasonably practicable preventative measure of ensuring that residents were not exposed to the risk of hazardous cleaning chemicals.

“Their failure to adequately assess the risks posed to residents by the storage of cleaning sanitiser in their rooms had fatal consequences.

“This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”