Care home failed to identify fatal asphyxiation risk13 September 2012
A care home must pay £178,000 in fines and costs after a 93-year-old resident died because of safety failings.
Elsie Beals was a resident at Aden Court Care Home inin Huddersfield, when she died from asphyxiation on 24 April 2010.
Mrs Beals, who was confined to a wheelchair, was helped to bed the previous evening by two care assistants. When staff checked on her in the early hours of the morning she was found dead with her head trapped between the mattress and the bed’s safety rail.
The HSE investigated the incident and identified that the safety rails hadn’t been fitted to the minimum setting, which meant there was a gap in between the mattress and the rails. It also learned that Mrs Beals had suffered cuts to her leg when one of them became trapped in the gap during two separate incidents, which took place within a five-month period prior to her death.
The HSE found staff were not trained to carry out regular ‘in-use’ checks to ensure the bed rails remained flush against the mattress. The company had also failed to carry out a thorough risk assessment.
HSE inspector Jacqueline Ferguson said: “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 Ltd, had no instruction in how to carry out risk assessments for the safe use of bed rails and no training in how to fit them correctly and keep them safely adjusted.”
New Century Care appeared at Leeds Crown Court on 10 September and pleaded guilty to breaching s3(1) of the HSWA 1974. It was fined £160,000 and ordered to pay £18,000 in costs.
In mitigation, the company, which operates 27 UK care homes and employs 1700 staff, said it had no previous convictions and regretted the oversights that contributed to the incident. It subsequently purchased new beds for the home, which came fitted with bed rails.
Sentencing the firm, Judge Penelope Belcher said: “This incident was eminently foreseeable and the company fell very short of the required safety standards.”
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