Death of dementia patient from hoist
In April 2008 an 87-year old dementia sufferer was being cared for by the Kent and Medway NHS Social Care Partnership Trust at a Unit in Sittingbourne. As he was being bathed he slipped from a hoist and fell, suffering fatal injuries. The HSE investigation found that there was poor communication between the nursing staff and the agency care workers. The care plan was unclear and was not shared with agency carers. There had been no consideration of the risk of using a bathroom in another ward which precluded active supervision of the agency workers. Care centre death from choking
In September 2012 Michael Breeze attended Shropshire Council’s run day services care centre, Hartley’s Day Centre, in Shrewsbury.The Centre caters for adults with learning disabilities. Mr Breeze was taken there for the day with a packed lunch provided by the carers at the residential home where he lived. At midday Mr Breeze started to eat his lunch. He started to choke and collapsed. He went into respiratory arrest and did not recover. He had a history of choking incidents. Appropriate safeguards were not put in place at the Centre despite these warnings.
Care home death from fire door
In November 2010 Irene Sharples, a 92-year old resident at Alexian Brothers Care Centre, was killed when a heavy fire door fell on her during renovation work.Healthcare Management Trust, the company which ran the home, engaged Rothwell Robinson Ltd to carry out renovation work. Mrs Sharples, who suffered from dementia, wandered into a room where building work was being carried out. A fire door fell on her and caused fatal injuries. Both companies had failed to make sure that the room was locked when it was unoccupied. The fire door had been removed during the building work and leant against wardrobes. Other hazards in the room included loose skirting boards, exposed wiring, broken glass and rusty nails.
Death from asphyxiation in care home
In April 2010 Mrs Elsie Beals, aged 93, a resident of the Aden Court Care Home in Huddersfield, run by New Century Care Ltd, died from asphyxiation after being trapped in the gap between her mattress and incorrectly fitted bed safety rails. Mrs Beal had been a resident for two years. She had been helped to bed on the evening before her death by two care assistants. She was checked before midnight and was due another check two hours later. When the care assistants entered her room, they found her dead, trapped in the gap between her mattress and the bed safety rail. The company had failed to train staff at the care home to fit bed safety rails properly. Staff had not been trained to carry out regular in use checks to make sure that bed rails remained properly adjusted, nor to carry out risk assessments for their use.
Bed safety rails are used extensively in the health and social care sectors to protect vulnerable people from falling out of bed. The risks of their use are well documented, actively published and widely recognised in the health care industry.