A man's death from choking while in community care could have been avoided, a fatal accident inquiry has found.
The fatal accident inquiry was held at Airdrie Sheriff Court
Graham Rattray, 42, who had severe learning disabilities, choked to death on 26 December, 2005, at his home in Moodiesburn, North Lanarkshire.
At the time, he was supported by Quarriers and a carer was in his home.
Sheriff Petra Collins found Mr Rattray's death might have been avoided if carers knew he had a choking risk and knew what first aid to administer.
She said Mr Rattray's death in the community had given rise to "serious public concern".
"Whilst it is not the purpose of this inquiry to examine the policy of 'care in the community' in general terms, obviously in implementing that policy there is a responsibility to ensure, in so far as possible, the safety of those cared for," she said.
The inquiry found the known risk of Mr Rattray choking and the action required to respond to this were not fully understood by carers.
Sheriff Collins said his death might have been avoided if his carers understood he had to be watched while eating and knew what first aid to administer.
When Mr Rattray choked, he was upstairs alone in his house and his carer was downstairs.
When he died, first aid training had not be provided to his support team - despite the fact this was recognised after a previous choking incident on 5 March.
Sheriff Collins said: "It is only right that the very sad circumstances of Mr Rattray's death should prompt a reappraisal of how best to care for the most vulnerable members of our society."
Quarriers, who provided full-time care, have implemented a series of recommendations after Mr Rattray's death.
Phil Robinson, chief executive of Quarriers, said: "We would like to express our deepest sympathy with the family of Graham Rattray for their loss.
"We acknowledge and accept the findings of the sheriff in this matter.
"Following his death, we carried out an extensive investigation into the health and safety and practice procedures in place at the time of his death."
He said they had identified some areas for improvement in the way that information and procedures were recorded and reviewed.
"We have long since implemented the areas for improvement in full," he added.