Western Isles Council fined £80k after care home failures led to 'preventable' death of vulnerable patient

Western Isles Council pled guilty to a charge under the Health and Safety at Work Act, with the local authority fined £80,000 in a ruling at Lochmaddy Sheriff Court on Wednesday.

Allan MacLeod, who had been diagnosed with dementia, had been a resident at Brendan’s Care Home in Castlebay – 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 March 9, last year, Mr MacLeod had been able to leave his bedroom without the knowledge of staff. He was only found around four hours after going missing and died a short time later in hospital.

An investigation by the Health and Safety Executive (HSE) found the care facility “should have made sure the home had stronger measures in place” after Mr MacLeod had made several previous attempts to leave.

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.”

Mr MacLeod had been placed in the home in October 2023 to allow him to be closer to 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 March 8 last year, having been settled in bed around 9pm, hourly checks were carried out to ensure his wellbeing. However, at 2am on March 9, 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 and was 10m from his bedroom. Police Scotland were alerted and launched a search.

Major emergency response after Mr MacLeod reported missing

Local Coastguard, RNLI and firefighters were called out to assist in the search. 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.

Make sure you keep up to date with news from across Scotland by signing up to our free newsletter here.

An investigation by the HSE determined he had made several previous attempts to leave the home.

The HSE said any measures staff had taken to prevent this, by fitting an electronic tag to his clothing that indicated his whereabouts, had been defeated by Mr Macleod having removed the device

A risk assessment carried out in December 2023 indicated Mr MacLeod would remove a tag if he located it.

It was only after his 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 Mr MacLeod’s death.