Health and safety horrors in care homes — Part 2

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

Scaldings and burns

In December 2008, Paul Cundy was living in a care home in St Austell, Cornwall. Comhome provided housing for vulnerable people and Solor provided care staff for the home. Cundy needed physical help with all aspects of his daily life. He was lowered into a bath by a care worker, using a hoist. He was so severely scalded that his skin was left hanging from his body. He was hospitalised for four weeks. There was no thermostatic mixing valve (TMV) fitted to the bath. This would have regulated the water temperature to below 44°C. Four internal maintenance reports had stated that the TMV was not functioning and identified it as high risk because the water from the hot tap was at 60°C. Cundy’s care plan, drawn up by Solor, did not refer to the risk of scalding and there was no system to ensure that care workers had read the plan. Comhome was fined £44,000 and Solor was fined £10,000.

In August 2012 Beatrice Morgan, aged 88, a resident of the Greencroft Nursing Home in Queensferry, Deeside, who was unable to walk, was lowered into a bath using a hoist. She cried out when she touched the water and suffered 9% 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°C. 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. Greencroft Care Ltd, a company in liquidation, was fined £5000.

In August 2013 Nicola Jones, a resident of a care home in Bathgate, was given a bath by Sharon Dunlop, a care support worker. Dunlop failed to check the temperature of the water. Ms Jones was scalded. She suffered 40% burns. She required major surgery and now has to use a wheelchair. Employees were supposed to check the water temperature before a service user bathed and to make a record of this check. The company did not provide written instructions confirming this. Real Life Options, the operator of the home, was fined £20,000. Dunlop was sentenced to 160 hours community service.

A Health and Safety Executive (HSE) inspector is reported to have commented after the case that the injuries had been easily preventable by the simple act of checking the water temperature. Employers should ensure that their staff are provided with a thermometer and training in the safety aspects of bathing or showering people for whom they provide personal care.

In May 2016, Angus John MacLennan, who had learning difficulties and received 24-hour support from Western Isles Council, suffered serious burn injuries while bathing. The Council had failed to adequately manage the risk of scalding despite having been made aware of the risk through their own risk assessment. Employees had received no training in managing the risks of scalding, including how to run the bath or check the temperature. They had not been provided with thermometers. The Council was fined £8000.

In 2011 an 89-year-old woman was a resident of the Old Wall Cottage Nursing Home, operated by European Healthcare Group Plc. She was receiving personal care from two employees when she died from scalding injuries. Bathroom taps were not adjusted to limit the safe temperature of the water. The company had policies and procedures in place, but they were deficient. The company had not effectively communicated information and instruction to staff, so that control measures could be properly implemented. An HSE inspector commented that all healthcare premises have a legal duty to control the risks of scalding injuries. The company was fined £100,000 plus £50,000 costs.

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°C. The company which owned the care home 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. Western Park Leicester Ltd, the operator of the home, was fined £100,000 plus £35,000 costs.

Fatal legionella exposure

In September 2012 Lewis Payne, aged 95, went to a care facility operated by Reading Borough Council. He had been in hospital and went to the care facility for intermediate care before returning to his home. He complained of tightness of the chest, shortness of breath, difficulty in breathing and nausea. He was readmitted to hospital and treated for Legionella’s disease. He died from legionella-related pneumonia.

Control and management arrangements at the centre were not sufficiently robust. Legionella training for key personnel were below required standards. There were inadequate temperature checks. Some of the checks of thermostatic mixer valves were done incorrectly. Showers were not descaled and disinfected quarterly as required. Flushing of little used outlets was reliant on one member of staff and there was no procedure for this to be done in the absence of that staff member. The failings were systemic and continued over a period of time. There was a history of legionella problems at the centre. Monitoring, checking and flushing tasks were the responsibility of the centre’s handyman. He was inadequately trained and supervised. There was no system in place to cover for him when he was away so that the requisite checks were not done. The Council was fined £100,000 plus £20,000 costs.

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. Healthcare Management Trust was fined £20,000 plus £7500 costs. Rothwell Robinson Ltd was fined £10,000 plus £7500 costs.

Trapped by bed rails

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 Beals 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. New Century Care Ltd was fined £165,000 plus £18,000 costs.

Care centre death from choking

In September 2012, Michael Breeze attended Shropshire Council’s 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. The Council was fined £25,000 plus £39,000 costs.