A 51 year old man from Aviemore, died after choking to death on food in the hospital.
James South, was suffering from respiratory problem and was confined at the Raigmore Hospital in Inverness. Due to his condition he was being fed through a tube.
But on February 6, the court found out that there was an error was made during the patient's administration of his lunch meal.
In ward 11, the patient was given soup, sausages and ice cream for his lunch, as supposed to feeding him using a tube , the hospital let him eat by himself.
During the investigation, they found a sign written above his bed, "nil by mouth."
NHS Highland admitted in court that there's a breach of health and safety in their part, they were fined £40,000 for the incident.
During the arraignment, the Health Board's Counsel Peter Gary QC admitted that the incident is an "isolated failure at operational level."
He said, "The failing relates to one ward in one hospital on one day. It is not a systematic failure and the organization has no previous convictions.
"But it is accepted had the system which was in place been robustly applied on that day, the death would not have occurred. It was not a willful disregard for patient safety, cutting corners or ignoring staff warnings."
"The system had worked up to that day and a meal-time co-ordinator has now been appointed," Mr. Gray added.
"This decision was taken prior to this incident and indicates that health and safety generally was a matter that was always at the forefront of the organization."
For Sheriff Margaret Neilson, when he was asked about the fine of the Health Board.
The Sheriff said, "The penalty imposed is not meant to measure the value of someone's life.
"A significant financial penalty is appropriate here. A death has occurred due to a public body's failure. But I note that it has taken steps to rectify the failings."
"This was a tragic but isolated incident."
Meanwhile, for Sandra South, who is the mother of Mr. South, refuses to give comment about ward 11.
She only 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," she added.
In a released statement of NHS Highland, it stated that "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 apologies unreservedly to the family."
