Health and safety horrors in care homes — Part 1

Barrister Robert Spicer brings together some of the worst reported health and safety prosecutions.

Fatal falls

Caring Homes Healthcare Group Ltd, the owner and manager of the Coppice Lea Nursing Home in Surrey, was fined £450,000 in 2017 after the death of a resident. In October 2013, an 87-year-old woman was a resident at the home. She fell 4m through her window, suffering fatal injuries. The window restrictor in place was easily overridden and was not fit for purpose. All windows which are large enough for people to fall through should be restrained sufficiently to prevent falls. The benchmark of 100mm should only be allowed to disengage using a special tool or key.

In October 2010 Patrick Foale, aged 75, was living at the Redmount Nursing Home in Devon. He fell down a flight of stairs in his wheelchair when he accessed a staircase after a fire door had been left open. He suffered fatal injuries. Foale spent much of his time in his own room on the first floor of the nursing home. He was capable of moving freely around the home in his wheelchair. The nursing home was aware that he had deteriorating eyesight and had been suffering periods of disorientation. The nursing home had failed to carry out a suitable risk assessment for him, had neglected to make provision for his deteriorating eyesight and did not act on his apparent disorientation. Your Health Ltd, the operator of the home, was fined £110,000 plus £26,000 costs.

In November 2010 Olga Llewellyn, a 92-year-old resident at the Brocastle Manor Care Home, Bridgend, 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. Hafod Care Association Ltd, the operator of the home, was fined £96,000. Between 2005 and 2010, there were 21 fatal accidents from falls from windows.

Kenneth Terrey, a dementia sufferer aged 74, was a resident at the Paternoster House Care Home in Essex. In March 2011, Terrey tried to leave the dementia unit. He climbed out of a window and fell to the ground. He suffered fatal injuries. At the time of the incident, a window restrictor, which would have prevented the window opening fully, was not working. Staff at the home had not been properly trained in how to carry out proper window safety checks and no window management safety system was in place. Barchester Healthcare Homes Ltd, the operator of the home, was fined £175,000.

In December 2012 a 63-year-old man, a resident of the Nada Residential and Nursing Home in Manchester, 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 10cm. The care home had failed to properly assess the risk of residents falling from windows and had not taken suitable action to prevent this from happening. The home was fined £8000 plus £597 costs.

Falls from hoists

In August 2010 May Ward, aged 100, was being moved by two carers at the Meppershall Care Home in Bedfordshire. 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 forward she fell out.

There was a history of serious safety breaches at the home. The Health and Safety Executive (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.

Mohammed Zarook, the director of the company which owns the home, 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, the company which owned the home, was fined £50,000 plus £36,000 costs. Zarook was fined £150,000 plus £100,000 costs.

In June 2013 Joseph Hobbin, who suffered from cerebral palsy and epilepsy, was assisted into a bath in his home by a care worker employed by Ark Housing Association Ltd. As his legs were lowered into the bath he suffered an epileptic fit. His legs remained in the water and he sustained extensive scalding to his feet and lower legs. He died in hospital.

Mr Hobbin needed support in all aspects of day-to-day living. The local authority contracted Ark to provide his care. Ark had not provided care workers with training or instruction in relation to bath and shower temperature. The company was not aware of guidance in relation to safe bathing. It did not provide thermometers to staff and did not carry out adequate risk assessments in relation to the bathing of service users, including the deceased. Ark Housing Association Ltd was fined £75,000.

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. The Trust was fined £107,000 plus £25,000 costs.

In November 2013, an 89-year-old resident at the company’s care home in Sudbury, Suffolk, was moved by two care workers, using a hoist, from her bed to a chair. She slipped through the hoist sling onto the floor. She suffered a fractured femur and ribs. She died two weeks later. The company did not have adequate health and safety arrangements in place to ensure that users could be safely hoisted. There was no manual handling policy. Individual risk assessments were inadequate because they failed to provide specific information about the equipment to be used. This resulted in some residents being hoisted with the wrong type or size of sling. Nurses and care workers had not been given suitable training and several slings were found to be unsafe to use. They had not been inspected or examined for six months. Disposable slings were being washed and reused. Chilton Care Homes Ltd, the operator of the home, was fined £60,000 plus £50,000 costs.