Western Isles Council has been fined after an elderly patient with dementia died after going missing from one of its homes. 

Western Isles Council has been fined after the death of a patient who went missing from St Brendan’s Care Home in Castlebay on the Isle of Barra.

The man, who had been diagnosed with dementia, had been a resident at the home – one of five operated by the council throughout the Western Isles – for around six months at the time of his death. Early on 9 March last year, he had been able to leave his bedroom without the knowledge of staff.

To avoid being observed, he had exited the home via the only door that was not alarmed and was 10 metres from his bedroom. Police Scotland were alerted and a search was initiated.

Local coastguard, RNLI and firefighters were called out to assist in the search and at around 0600, the coastguard helicopter detected a heat signature near the home on the patio of a residential property. He 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.

Tragic and preventable 

“This was a tragic and preventable death,” said Health and Safety Executive (HSE) inspector Ashley Fallis. “The council should have made sure the home had stronger measures in place.”

A risk assessment carried out by Britain’s national regulator for workplace health and safety in December 2023 determined that the patient had made several previous attempts to leave the home. Any measures that staff had taken to mitigate this, by fitting an electronic tag to his clothing that indicated his whereabouts, had been defeated as the patient removed it. 

It was only after his death that 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 the patient’s death.

Western Isles Council pleaded guilty to breaching Sections 31 and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974 and was fined £80,000.