Council fined after ‘preventable' death of care home dementia patient
He was found near the home about four hours after going missing, with facial injuries consistent with falling, and died a short time later in hospital.
Western Isles Council was fined £80,000 at Lochmaddy Sheriff Court on Wednesday August 6 after it admitted breaching the Health and Safety at Work Act 1974, the Health and Safety Executive (HSE) said.
Mr MacLeod had been a resident at the home – one of five operated by the council throughout the Western Isles – for about six months at the time of his death.
An HSE investigation by the Health and Safety Executive (HSE) determined that he had made several previous attempts to leave the home.
It found that 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 removing it.
HSE said that on March 8, having been settled in bed at about 9pm, hourly checks were carried out to ensure he was alright however, at 2am on March 9, staff found that he was not in his bed.
Investigations found that he had left the home via the only door that did not have an alarm which was located 10 metres from his bedroom.
Following a search involving the coastguard, RNLI and firefighters, he was found near the home on the patio of a residential property.
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.'
HSE said that after Mr MacLeod's death, 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 he died.
A spokesperson for Western Isles Council (Comhairle nan Eilean Siar) said: 'Comhairle nan Eilean Siar once again extends its sincere condolences to the family and friends of the late Mr Allan F MacLeod for the circumstances surrounding his tragic passing on 9 March 2024.
'Yesterday at Lochmaddy Sheriff Court, the comhairle accepted that health and safety shortcomings contributed to the tragic incident and pled guilty to the charges brought by the procurator fiscal.
'The comhairle hopes that the conclusion of this case will offer the family some closure.
'The door security system in use at St Brendan's Care Home was a key factor in this case.
'A new door security system had been procured but at the time of the incident the works to install it had not been completed.
'Comhairle nan Eilean Siar is committed to the delivery of high standards of care to all residents in our residential homes. In this instance these standards were not fully met.
'The comhairle has implemented health and safety improvements and will continue to work with the Care Inspectorate to ensure that our residential homes operate to the highest possible standards.'
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