A health board has been fined £40,000 for causing the death of a patient who was not to receive food orally, after a student nurse gave him sausages and mash for lunch.
James South, from Aviemore, was being fed via a tube through his nose and had a sign above his bed in Raigmore Hospital, Inverness, which is run by NHS Highland, with the words 'nil by mouth' written in red pen.
But an auxiliary nurse helped him fill out his lunch menu and a student nurse handed him his soup, sausages and ice cream in ward 11, a respiratory unit, on February 6 last year.
Fifteen minutes later, the 51-year-old was dead, having choked to death on his main meal.
His mother Sandra, from Grantown on Spey was at Inverness Sheriff Court to hear the circumstances leading up to the death of her son.
She said: "The fine is fair. It is not the money, but the principle which concerned me. James had been doing so well.
"But the human element came into it. I do not bear any grudges and want to say that the care he received in intensive care was wonderful. However I wouldn't like to comment on what I think about ward 11."
The court heard measures were in place to ensure each patient's dietary requirements were met and communicated to staff at safety briefings and shift handovers.
Mr South was admitted on December 27 2013 suffering from a variety of health conditions including pneumonia. But three days later, he suffered respiratory failure and was transferred to intensive care and put on a ventilator.
On New Year's Day 2014, the decision was taken to feed him through a nasal tube and when his condition improved, he was again transferred to Ward 11 because "swallowing was not felt to be safe.", fiscal depute Geoffrey Mayne told the court.
He added that a student nurse was on her first day on the ward and a staff nurse, who was aware of Mr South's limitation was assigned to oversee her.
"However the staff nurse became severely unwell and another staff nurse was assigned. An auxiliary, who had attended the handover but was unaware that Mr South was nil by mouth then began collecting menu cards.
"She asked him what he wanted and she completed the card for him. A consultant visited Mr South and asked how staff could make him more comfortable to which he replied that he wanted to eat.
"The consultant explained that he was unable to eat due to swallowing problems."
However later that day, the meal was delivered to Mr South by the student nurse.
"Fifteen minutes later, during the routine post meal check, Mr South was found to be unresponsive. Mashed potato was noticed on the side of his face and inside his oxygen mask.
Mr Mayne said Health and Safety Executive concluded that NHS Highland did not effectively managed the risk to patients with dietary requirements and did not have an effective system in place for communicating the nil by mouth status of Mr South. Mr Mayne added.
"He was under the care of NHS Highland and the responsibility to manage his swallowing difficulties rested with NHS Highland."
The Highland Health Board, also known as NHS Highland , admitted a breach of Health and Safety.
Their counsel, Peter Gray QC said: "This was an isolated failure at operational level. It is not a systematic failure."
Sheriff Neilson said: " The penalty imposed is not meant to measure the value of someone's life. A significant financial penalty is appropriate here."
Dr Rod Harvey, Board Medical Director for NHS Highland, added: "The systems we had in place were not consistently good enough and had they been more effective this death could have been avoided. This is something we deeply regret and for which we apologise unreservedly to the family."
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