St David’s Care Forfar Limited, who run St David’s Residential Home in Forfar, pled guilty to a health and safety at work breach committed in January 2017.

The procurator fiscal depute told Dundee Sheriff Court that on 12 January 2017, Georgina Norrie, a resident at St David’s, was allowed to wander out of the home and subsequently died of hypothermia.

Ms Norrie had learning difficulties and dementia and was known to wander within the home at night.

Her room was fitted with a motion sensor to alert staff when there was movement in her room. The alarm did not activate when she left her room as a piece of tape had been applied to the sensor.

At the time of the incident, all entrances and exits to the building were locked or alarmed, except for the fire exit in the dining room.

The court heard that on 11 January the two care assistants on duty checked on all residents at 10.00 pm and then again at 2.00 am. They found Ms Norrie in bed and her alarm switched on. They were unaware of the tape on the sensor.

Ms Norrie was not in her room when it was checked again at 6.10 am. Following a search, she was found outside lying at another entrance door. Ms Norrie was carried back to her bed where she died a short time later.

The prosecutor stated that it was foreseeable that a resident could use the fire door during the night to exit the building without staff being aware that they had left.

A suitable and sufficient risk assessment would have identified suitable controls to prevent a resident from exiting the home during the night or, where the means of exit required to be maintained for fire safety, suitable controls would have identified a means of alerting staff to a resident having exited the building during the night.

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 St David’s Care Forfar Ltd had taken the reasonably practicable preventative measure of having the fire door alarmed.

“Their failure to have sufficient controls in place to manage this significant risk meant that staff were unaware that a resident had left the building on a cold January night and led to the death of Georgina Norrie.

“This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”