Care home company fined £250,000 over resident’s choking death

A company which runs care homes was fined £250,000 today following the death of a resident who choked on a ham sandwich.

Robinia Care Group Limited, which runs 90 care homes, put “profit before safety” at the home at the time of the death of Jesse Moores, Judge Peter Ader told Wood Green Crown Court in London.

Mr Moores, 26, who was autistic, hyperactive, suffered from Tourette’s Syndrome and had a history of choking, was found lying motionless in his room at the Chine Care Home in Enfield, north London.

A piece of sandwich the size of a golf ball was later found stuck in his throat.

The judge imposed a fine of £1,200 on the home’s deputy manager at the time, Patience Etchu-Abangma, 53, of Enfield, north London.

She was convicted at an earlier trial of breaching her health and safety duty.

Robinia pleaded guilty to three counts of failing to comply with its health and safety duty.

Etchu-Abangma’s trial heard that she left Mr Moores, of Friern Barnet, north London, with two agency care workers – one of whom was an illegal immigrant – while she went off to do a secret second job.

The judge told Etchu-Abangma: “You bear a very heavy responsibility in relation to Jesse Moores.”

He said that she had another job, at a school, may have played a part in the death, which happened in November 2005, and was in breach of her contracted employment.

“It made it impossible for her to care for people at The Chine when she went to school.”

He said when one of the agency nurses called her, to tell her about Mr Moores, she said she would ring the emergency services, but there was a delay of 15 minutes before the ambulance was called.

“That enabled her to get back to the home from her school before the ambulance arrived,” said the judge.

“She said to the ambulance operator that people were doing CPR. That was a blatant lie, nobody was doing CPR.

“If she had told the truth, the operator would have given her instructions as to how someone should conduct artificial respiration on the patient.”

As for the company, it had complaints from the home’s management itself and from parents that there were not enough staff, but a culture had developed where the board knew about problems of extra expenditure but not lack of staff, he said.

“A case of profit before safety is made out,” the judge said.

In the end the company shut the home.

The judge said: “Jesse Moores’ own actions caused his death, he might have died even if complaints (about lack of staff) had been heeded.

“But the risk might have been reduced or possibly even avoided – it is impossible to say.”

The court also heard today that Glen von Malachowski, deputy chief executive of Robinia at the time of the death, told police investigating
it: “S*** happens in our business.”

He was interviewed in May 2006 by which time he was chief executive and he said: “S*** happens in our business, unfortunately.”

Incidents of other chokings “never went up the chain of command”, he said.

He also told police Robinia “deeply regrets” what had happened and Peter Harrison QC, prosecuting, added that Mr von Malachowski also later regretted using the phrase “S*** happens.”

The court heard that none of those who were directors at the time were currently employed by Robinia.

Mr Moores’ father, Bob, said: “I can’t tell you how affronted I was to hear that remark. His comment was unprofessional, completely uncalled for and crass.

“For someone in his position to make a comment like that was outrageous.”

Mr Moores, 61, an antique dealer from Godalming, Surrey, said he was “very happy” with the sentences.

“It’s probably a record fine for a care home group, and it all means that Patience is unlikely to work in the care industry again, reassures me.

“She lied and made serious mistakes, I have very strong feelings about that woman.”

Mr Moores added: “A recent report from the regulator suggests that Robinia has turned a corner and is providing a good service in the last six to nine months.

Kit Doleman, Robinia chief executive, said: “We remain deeply saddened at the death of Jesse Moores.”

“As we said immediately after his death, we would like to express again the deep sympathy that we all feel for his family who have not only had to deal with Jesse’s death but also have had to relive the events throughout these proceedings.

“We respect the Judge’s decision and sentencing and we would like to stress that we have learnt from the events of November 3, 2005 and those leading up to it.

“We will be working with Enfield Council in their review of the events at the Chine and we will ensure that we do this in an open and transparent manner.

“Once again, we would like to reiterate how sorry we are about Jesse’s death and stress the significant changes that we have made to ensure that the tragic events at the Chine are not repeated.”