The Edinburgh-based organisation, which provides care, support, and housing for adults with complex needs, pled guilty to a health and safety at work breach committed between October 2018 and November 2019.

The procurator fiscal depute told Kirkcaldy Sheriff Court that on 30 November 2019, Shirley Breeze choked after her support worker gave her a marshmallow that was not suitable for her dietary needs. She then suffered two cardiac arrests and a seizure which led to her being placed in an induced coma. She died on 2 December 2019.

Miss Breeze was a service user of Ark since October 2006 and was provided with support to live independently in her own flat in Cowdenbeath. She had severe learning disabilities and received 24/7 care.

Miss Breeze had been assessed as at risk of choking following an incident in June 2017. She had been placed on a modified ‘soft’ diet and had an eating and drinking plan in place along with a menu of suitable foods.

Ark failed to ensure staff were given adequate training on her diet or sufficiently familiar with the high-risk food groups and the practice of changing or adding items to the menu planner contributed to unsuitable foods being given to Miss Breeze.

The prosecutor stated that it was entirely foreseeable that if support workers were not properly trained or instructed in the suitability of foods, they might offer foods which were unsuitable, and choking may result.

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS), said: “The death of this vulnerable woman could have been prevented if suitable training and procedures had been in place.

“Ark Housing Association Ltd left service users at risk by failing to ensure staff had the relevant knowledge and training on modified diets for those in their care.

“This prosecution should highlight to other similar organisations that failure to fulfil their health and safety obligations can have tragic consequences and remind them they will be held accountable for their failings.”

A spokesperson for Ark Housing Association said: “This was a tragic accident which cost the life of someone we had looked after for 20 years. We immediately identified where we had failed Shirley and took full responsibility for this tragic accident. Over the past three years we have worked tirelessly to develop the most robust approach to training and support for our staff teams in this area.

“We hope those actions, and our work with a number of other agencies in our sector, can play an important role in preventing any repeat of this awful incident.”