The biggest care home provider in the UK has been ordered to pay £170,000 in fines and costs after a "vulnerable and elderly" woman choked to death on fish and chips.
Four Seasons Health Care (England) was prosecuted by the Health and Safety Executive (HSE) after an investigation found that Rita Smith, 75, should only have been provided with pureed food as she had swallowing difficulties and was at risk of choking.
The HSE said its investigation found there had been "an alarming lack of communication", with many staff unaware of Miss Smith's "well documented" needs.
Her family described the death as "disgraceful and unnecessary".
Preston Crown Court was told that Miss Smith, who suffered from dementia and motor neurone disease, was admitted into Euxton Park Care Home in November 2010.
The home was made aware that Miss Smith had difficulty swallowing, needed pureed food on a teaspoon and supervision by a carer while eating, the HSE said.
Two weeks later, she was given fish and chips in a cone along with other residents while she was at a film and supper evening in the care home on December 1.
mortem found the primary cause of death was choking.
The HSE investigation into the incident found neither of the staff who organised the film and supper evening had been made aware that Miss Smith could not eat solid foods.
A specialist assessment carried out at the local hospital, recommending she be supervised at meals and prompted to slow down and swallow twice during each mouthful, had been provided to the care home but was not communicated to staff, the HSE said.
It added that a care plan and risk assessment had also not been completed by Four Seasons for Miss Smith on her arrival at the home, which would have identified the need for a care worker to feed her pureed food during meal times.
It also emerged that a carer at the home had left Miss Smith alone to eat un-pureed Weetabix a few days before the film and supper evening.
Four Seasons Health Care (England) Ltd, part of the Four Seasons Health Care group which runs more than 500 care homes and specialist care centres in the UK, pleaded guilty to a single breach of the Health and Safety at Work etc Act 1974, the HSE said.
The company, of Groves Road in Douglas, Isle of Man, was fined £125,000 and ordered to pay £45,000 towards the cost of the prosecution.
Speaking after the hearing, HSE inspector Shellie Bee said: "This was a tragic death which could have been avoided if Four Seasons Health Care had made sure systems were in place to protect residents.
As it was, a vulnerable and elderly woman paid the price for their failures.
"Our investigation found there had been an alarming lack of communication with many staff unaware of Miss Smith's medical needs, despite them being well documented.
"She should never have been given un-pureed food, let alone been left by herself to eat it during the film and supper evening. But her condition meant she did not have the mental capability to refuse the meal or recognise the danger.
"Euxton Park Care Home was made aware of the risk of Miss Smith choking on un-pureed food when she arrived, but failed to act properly and as you would expect on this information. Sadly, she lost her life as a result."
Miss Smith's family also released the following statement after the case: "We are grateful to the Health and Safety Executive for the professional and sensitive way in which they have liaised with our family following the disgraceful and unnecessary death of Rita, three years ago.
"Rita was in the Euxton Park Care Home for a mere two weeks before this frightening and tragic event occurred.
"Our hope is that the seriousness and financial implications of this case for the company will ensure that nothing like this will ever happen again at a Four Seasons or any other care home. This would mean that Rita's tragic death will not have been entirely in vain."