HAZARDOUS SUBSTANCES
Release of toxic substances
In November 2011 methyl iodide, a highly toxic substance which can affect the central nervous system, was released into the atmosphere at Archimica Chemicals Ltd and Euticals Ltd’s site in Flintshire, because of poorly written procedures. In February 2012 an agency worker was exposed to the same substance because he was provided with inadequate respiratory protection. In June and July 2012 a worker was exposed to the same substance after having been given inadequate decontamination training. In July 2012 a worker suffered severe and permanent injuries following exposure to the same substance, having been issued with poorly fitting respiratory protection. In November 2012 three workers were exposed to dichloromethane, a hazardous substance with potentially fatal effects, when a process vessel overflowed. Both companies are now in liquidation and it is reported that the site is being decommissioned.
Drugs exposure at veterinary practice
Employees of Davies Veterinary Services Ltd in Bedfordshire, which included a total of 125 vets, nurses and support staff, were exposed to harmful drugs over a four-year period. The fume cabinet used for animal chemotherapy drug preparation was not used in the way for which it was designed. The employees were potentially exposed to substances which are harmful to human health and can cause cancer. A dangerous occurrence was reported to the HSE in 2011 by one of the vets who believed that the fume cabinet was unsuitable. There was no system of work in place to prevent or reduce the risk of exposure to employees. There had been no maintenance of the fume cupboard for many years. Cleaning procedures were inadequate.Employees had not been given any safety training in the use of the fume cupboard. There was inadequate personal protective equipment and no monitoring systems. From July 2007 until September 2011 workers at the practice could have been exposed to the drugs.
HOSPITALS
Death of patient from drowning
Mansoor Elahi was an inpatient at Birch Hill Hospital, operated by Pennine Care NHS Foundation Trust . On September 5 2013 he was taking part in a prearranged rafted canoeing activity provided by an outdoor activities centre in partnership with the Trust. He removed his buoyancy aid and jumped into the water to commit suicide. The Trust had failed to carry out a risk assessment for the property or to adequately assess the deceased’s suitability to attend. His actions had been entirely foreseeable because he had tried to enter the water on a previous occasion. If the Trust had carried out a suitable assessment it would not have allowed a vulnerable person the opportunity to end his life.
Death of patient in fall
Adam Withers was detained as a patient at Epsom Hospital, run by Surrey and Borders NHS Foundation Trust/ In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied. An HSE inspector commented after the case that if the Trust had carried out a suitable assessment and made the appropriate changes they would not have allowed a vulnerable person the opportunity to end his life.
Hospital window death fall
In June 2010 Robin Blowes was admitted to a hospital operated by Southend University Hospital NHS Foundation Trust for surgery. He developed signs of confusion and was moved to a side room. He fell nine metres through a window which was fitted only with a single restrictor and suffered fatal injuries.The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. The window of the deceased’s room was fitted only with a single angle bracket restrictor which was bent to one side, allowing the window to be fully opened. Since 1989, guidance has been in place which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.
In–patient fall death
Mark Scott-Green was an in-patient at Royal United Hospital Bath. He became confused and vulnerable. The NHS Foundation Trust authorised a Deprivation of Liberty Safeguard. This authorised the forcible return of patients to their rooms for treatment in their best interests. In November 2012 hospital security returned Scott-Green to his second-floor room. He fell from his window and was found dead in the hospital courtyard. The window was fitted with one restrictor. It was large enough to flex . the gap was larger than the recommended 100mm standard. Other windows at the hospital were not adequately restricted. The HSE issued an improvement notice to ensure that all restrictors were suitable and prevented the windows opening more than 100mm. A safety alert had been issued by the Department of Health to all NHS Trusts informing them of the risk of relying on one window restrictor.
Death of patient from drowning
In September 2014 Joan Darnell, aged 78, was admitted to a specialist dementia ward in a hospital operated by the Norfolk and Suffolk NHS Foundation Trust. In October she was reported missing and was found face-down in a bath full of water. She had dies from drowning. The Trust did not have adequate policies or procedures in place for managing patient safety. It had failed to complete an appropriate risk assessment for the deceased and to take steps to prevent vulnerable patients having unsupervised access to bathrooms. Nor did it have adequate systems and arrangements in place to ensure that patients under its care on the ward were effectively monitored.
Death of patient from drowning
In September 2014 Joan Darnell, aged 78, was admitted to a specialist dementia ward in a hospital operated by the Norfolk and Suffolk NHS Foundation Trust. In October she was reported missing and was found face-down in a bath full of water. She had dies from drowning. The Trust did not have adequate policies or procedures in place for managing patient safety. It had failed to complete an appropriate risk assessment for the deceased and to take steps to prevent vulnerable patients having unsupervised access to bathrooms. Nor did it have adequate systems and arrangements in place to ensure that patients under its care on the ward were effectively monitored.
Death of psychiatric patient
In August 2010 Gary Niven, a patient with a history of depression, hanged himself in the A&E department of Crosshouse Hospital in Kilmarnock. He died a few days later. The risk of psychiatric patients being left alone was identified by NHS Ayrshire and Arran. It had procedures for staff to follow but these were not followed for Mr Niven. Mr Niven had been taken by ambulance to the hospital after saying he was feeling suicidal and had already attempted to hang himself. He was taken to a room where the doors were always left open so that he could be observed. A charge nurse noticed that the doors were closed and Mr Niven was found inside, having made a ligature from the arm of his jumper.
Scaffolding fall
W Hughes and Son Ltd was engaged to replace a roof in the Royal Preston Hospital. It installed scaffolding to reach the roof but failed to fence off the steps leading to the scaffold. A 17 year old mental health patient climbed the scaffolding. She fell six metres and suffered a fractured spine and pelvis. An HSE inspector is reported to have commented after the case that construction firms have a legal duty to make sure that construction sites are secure and clearly signed.
Deaths of patients: Mid Staffordshire Hospital Trust
The HSE investigated the deaths of four patients between 2005 and 2014 at Cannock and Stafford hospitals. Three of the patients suffered fatal flaws and a fourth suffered a severe anaphylactic reaction after being given penicillin despite having informed the hospital on several occasions that she was allergic to it. The HSE investigated the Trust in accordance with its policy to investigate deaths in the health sector where there was evidence that standards had not been met because of a systematic failure in management systems. The Trust failed to follow a number of its own policies in relation to handing over information, completing records, carrying out falls risk assessments and the monitoring of care plans.
Bacteria exposure
In January 2011 a test vial containing a strain of multi-resistant TB bacteria smashed when it fell to the ground while being handled. Four employees risked exposure but none suffered adverse effects. The Royal Brompton and Harefield NHS Foundation Trust should have developed and implemented a safe system of work to prevent such an incident. It should also have better implemented appropriate and adequate control measures, and ensured that staff were suitably trained. In 2002 the HSE had issued an enforcement notice for the same laboratory facility for failing to ensure that it was sealable for disinfection. Critical control measures, including the laboratory sealability and filters, were not examined, monitored, tested or maintained.
Hospital window fall
In September 2011 a patient in a ward at West Suffolk Hospital climbed up to a bay window in an attempt to escape. She fell three metres to the ground below and suffered a broken vertebra and a punctured lung. The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. There was no window restrictor fitted to the window. A survey conducted by the Trust after the incident identified a number of issues with window restrictions. Guidance has been available since 1989 which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.
Death of patient in fall
Adam Withers was detained as a patient at Epsom Hospital. In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied.
Death of patient in hoist
In April 2012 John Biggadike, a patient at The Pilgrim Hospital in Lincoln, died from internal injuries after falling onto an exposed metal post on a standing aid hoist which staff were using to support him. The kneepad on the hoist had been incorrectly removed. This left the metal post exposed. The United Lincolnshire Hospitals NHS Trust did not have systems for training and monitoring the way in which staff used the hoist. Unsafe practices had developed. A spokesperson for the HSE is reported to have commented after the case that if staff had received effective training and monitoring in the use of the hoist, the death could have been avoided.
Death of diabetic
Gillian Astbury, a 66 year old Type 1 diabetic, died from diabetic ketoacidosis at Stafford Hospital in April 2011 because of failures to implement basic handover procedures and to ensure essential record keeping. Staff at the hospital did not follow or even sometimes look at medical notes which stated that Ms Astbury needed insulin, regular blood tests and a special diet. The system for communicating patient needs at staff handovers was inconsistent. Record keeping and monitoring of patient care plans were far below acceptable standards. Mistakes were made at up to eight shift changes and 11 drugs rounds. The failure to administer insulin was the direct cause of Ms Astbury’s death.
Mid Staffordshire NHS Foundation Trust has been the subject of two major inquiries into events at Stafford Hospital between 2005 and 2009.
Death of nil-by-mouth patient
In December 2013 James South was admitted to Raigmore Hospital suffering from a number of complaints. He was treated with naso-gastric feeding. A label stating that he was to be Nil by Mouth was placed at the head of his bed. South died following the lunchtime meal which was served to him. He was found to have mashed potato on his face and inside the mask which he had been wearing. The Highland Health Board had failed in its duty to ensure the health, safety and welfare of those not in its employment and had not taken all reasonable steps to ensure that risks to patients with special dietary requirements were managed.
NHS Hospital Trust fined after series of deaths
Between June 2011 and November 2012 five elderly patients died while being cared for in hospitals run by the Shrewsbury and Telford Hospital NHS Trust. Mohan Singh, aged 74, was admitted to the Princess Royal Hospital in Telford. It was recommended that he had bed watch. He fell to the floor and suffered fatal injuries. Eileen Thomson, aged 81, suffered three falls in the hospital, She died in May 2012. Edna Evans, aged 92, suffered a fall in the hospital. She died in October 2012. The post mortem found that the injury which she suffered in the fall contributed to her death. Ada Clarke, aged 91, died in October 2012 after falling out of bed in the hospital. Gerald Morris, aged 72, fell in the Royal Shrewsbury Hospital, He suffered a fractured hip and died in November 2012. Fall prevention measures, including close supervision of those in a confused mental state, were not properly applied. This was made worse by poor consideration and communication surrounding measures to protect against falls.