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  • Writer's pictureRobert Spicer

Care home deaths: recent prosecutions

Care homes: recent prosecutions

Prosecutions of care home owners (whether individuals or companies) for serious breaches of health and safety regulations, often with tragic consequences, are reported with depressing regularity. The following summaries illustrate the range of breaches which have been successfully prosecuted by the Health and Safety Executive.

In March 2015 GA Projects Ltd, the company which owns the Meppershall Care Home in Bedfordshire, and Mohammed Zarook, the company’s director, were fined following the death of a resident.

In August 2010 May Ward, aged 100, was being moved by two carers at the Home. She fell from a hoist and suffered multiple fatal injuries.

The two carers had been employed for less than a year. The hoist used to move Mrs Ward had a complex operating procedure and the carers had not been trained in how to use it safely. The hoist was not recommended by the local authority as being suitable for Mrs Ward’s condition. She was not securely positioned and when she moved forwards she fell out.

There was a history of serious safety breaches at the Home. The HSE had served five improvement notices between October and December 2010 related to resident handling, risk assessment and a lack of competent health and safety advice.

Another resident had suffered leg fractures after falling when being moved from a wheelchair to an armchair in September 2009.

Zarook had no knowledge or experience of running care homes. He proceeded to take vulnerable residents into his three care homes. There was no evidence that he had taken steps to fulfil his health and safety obligations through the provision of training and the management of risks most commonly associated with the care industry, including resident handling.

The Care Quality Commission had inspected the Home and had given it poor ratings. The Home was closed in July 2013.

GA Projects Ltd was fined £50,000 plus £36,000 costs for a breach of section 3, Health and Safety at Work, etc Act (HSW Act), for failing to ensure the health and safety of non-employees.

Zarook was fined £150,000 plus £100,000 costs under section 37, HSW Act.

In January 2015 Western Park Leicester Ltd, a company which owns a care home in Leicester, was been fined following the death of a vulnerable patient.

In May 2012 Walter Powley, aged 85, was admitted to Western Park View, a care home, after his family was advised that he could not be safely left at home because of his risk of falling.

Powley fell in his room at the home. He was trapped between a wardrobe and a radiator. He suffered serious burns to his legs from the radiator pipe and valves. The injuries were fatal.

The pipes and valves were not covered and had temperatures of 73 degrees centigrade.

The company was aware that the deceased was at risk of falls and injury and that staff should be vigilant. It had failed to assess the risks in his room and had not taken appropriate action to control and manage the risks.

The company was fined £100,000 plus £35,000 costs for a breach of section 3, HSW Act, for failing to ensure the health and safety of non-employees.

An HSE inspector commented after the case that this had been a foreseeable and preventable fatal accident. The scalding or burning risks from the pipes were longstanding and could have caused injury to any resident. The company had failed to heed published guidance from the HSE about the need to cover hot pipes and valves.

In November 2014 Hafod Care Association Ltd, the owner of Brocastle Manor Care Home in Bridgend, was fined after an elderly resident suffered fatal injuries.

In November 2010 Olga Llewellyn, a 92-year old resident at the home, suffered fatal injuries when she fell from her bedroom window.

All the windows at the home were fitted with the same type of window restrictors. These were unsuitable because they could be easily overridden and the windows opened wide.

The company was fined £96,000 plus £100,000 costs for a breach of section 3, HSW Act, for failing to ensure the health and safety of non-employees.

An HSE inspector made the following comments after the case:

  • Between 2005 and 2010 there were 21 fatal accidents from falls from windows.

  • Window restrictors should restrict the opening to 100 mm, be robust and not able to be overridden without the use of a specialist tool or key.

  • In this case, the risks were particularly high because of the very low window sill height.

Greencroft Care Ltd, the owner of Greencroft Nursing Home in Queensferry, Deeside, was fined in September 2014 following the death of a resident.

In August 2012 Beatrice Morgan, aged 88, a resident of the care home who was unable to walk, was lowered into a bath using a hoist. She cried out when she touched the water and suffered nine per cent burns from the scalding water. She later died from her injuries.

The temperature of the water was not properly controlled to prevent it exceeding 44 degrees Celsius. Mixing valves had been fitted to control the temperature but they had not been properly maintained.

Staff at the home had been instructed to check the temperature of bath water with a thermometer but no checks were made by management to ensure that this was done. The company had failed to adequately assess the risks of using hot water and had failed to provide sufficient training, instruction and supervision.

The company was fined £5000 for a breach of section 3, HSW Act. The court commented that if the company had not been in liquidation, the fine would have been at least £100,000.

A spokesperson for the HSE commented after the case that the incident could have been avoided if the company had observed the readily available guidance on bathing vulnerable people. Nursing homes and other organisations caring for vulnerable people must make sure that they fit and maintain the right kind of mixer on hot bath taps and properly supervise their staff.

In May 2014 the Nada Residential and Nursing Home in Manchester has been fined following an incident in which a resident suffered serious injuries when he fell from a window.

In December 2012 a 63-year old man, a resident of the care home, suffering from dementia, was found below his bedroom window suffering from multiple fractures. He told staff that he wanted to get some fresh air.

The risk of residents falling from open windows was well known in the care home sector. The windows should have been fitted with restrictors to prevent them opening more than ten centimetres.

The care home had failed to properly assess the risk of residents falling from windows and had not taken suitable action to prevent this happening.

Nada Residential and Nursing Home was fined £8000 plus £597 costs for a breach of section 3, HSW Act, for failing to ensure the health and safety of non-employees, and under regulation 3, Management of Health and Safety Regulations 1999 for failing to make a suitable and sufficient risk assessment.

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