Care homes safety failure leads to elderly womans death
12th September 2012
The owners of a West Yorkshire care home have been told to pay £183,000 in fines and costs after a frail 93 year-old widow died because established safety measures were neglected.
Mrs Elsie Beals asphyxiated after becoming trapped in the gap between her mattress and incorrectly-fitted bed safety rails at Aden Court Care Home in Huddersfield on 24 April 2010.
New Century Care Ltd of Sidcup, Kent, a private company with around 27 UK care homes,was prosecuted for a serious safety breach by the Health and Safety Executive (HSE) after it investigated the incident.
Leeds Crown Court was told today (10 September) that the company, which has some 1,700 employees, had failed to train staff at Aden Court to fit bed safety rails.
HSE found also that staff were not trained to carry out regular 'in-use' checks to make sure bed rails remained properly adjusted, or to carry out risk assessments for their use.
The court heard that Mrs Beals, formerly of Lepton, Huddersfield, who had been resident at Aden Court for two years, had been helped to bed the previous evening by two care assistants. She had been checked just before midnight and was due another care check two hours later.
When the care assistants entered the room in the early hours of 24 April, Mrs Beals could not immediately be seen in bed. As they went to the side near the window they saw she had become trapped in the gap created between the mattress and the safety rail. It was obvious to staff that she was dead.
New Century Care Ltd of River House, Maidstone Road, Sidcup, Kent, was fined £160,000 and ordered to pay £18,000 in costs for breaching Section 3(1) of the Health & Safety at Work etc Act 1974. The firm had pleaded guilty at a previous hearing.
After the case HSE Inspector Jacqueline Ferguson, who investigated the incident, said that New Century Care's safety failings came despite widespread Government medical advice on the safe use of bed rails in the health and social care sector.
"This was a terrible tragedy that could have been so easily avoided. 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.
"There are several causes of injury involving bed rails used incorrectly. The most serious is asphyxiation as a result of being trapped by the head or neck. This can happen because a rail is not designed for use with a particular bed, or because of poor bed rail design leading to too much space between the rails.
"Staff at Aden Court, owned and operated by New Century Care, had no instruction in how to carry out risk assessments for the safe use of bed rails and no training how to fit them correctly and keep them safely adjusted.
"If anything positive is to come out of this very sad incident, it is that other employers take note and be aware that HSE will not hesitate to take action against those who fall so far below the required standards."
In the five years to 2005 there were at least ten deaths and a number of major injury incidents in which the use of bed rails was implicated. More recently, in 2010 a NHS Foundation Trust in the South East was fined £50,000 after the death of a disabled man whose head became trapped between bed rails. The following year, a nursing home was fined £70,000 when an elderly lady died of asphyxiation when she became trapped between a mattress and a bed rail in 2008.