A Bupa care home has been fined £100,000 after an immobile elderly resident died after falling out of a hoist while being lifted out of her bed.
Irene Evans, 91, was a resident at the Parklands Court Nursing Home in Bloxwich, Walsall when the incident took place on 31 January 2007. She suffered dementia and was unable to move without assistance. On the day of the incident two carers were trying to move her from her bed to a chair.
Three weeks earlier the care home had purchased a new hoist to lift Mrs Evans as the previous hoist was uncomfortable and left her with sores. The device places a sling underneath the patient, which is attached by means of a series of hooks, loops and clips to the mechanically-operated hoist.
The new equipment had a safety pommel, which was meant to be placed between Mrs Evans’ legs to prevent her from being able to slide out of the sling. But staff at the home had not received any information or training in the use of the sling and began lifting Mrs Evans without attaching the pommel.
While the hoist was stationary one carer turned away to pick up the elderly resident’s slippers and the other carer was behind the mast of the hoist. Mrs Evans slipped out of the hoist and fell two feet to the ground. She suffered a five-inch wound across her scalp and bruising to her head, and she died in hospital ten days later owing to her injuries.
HSE inspector Amy Kalay revealed that management at the home had failed to update the manual handling risk assessment after the new hoist had been purchased. She also explained that if both members of staff had kept their attention on Mrs Evans when the hoist was stationary they would have noticed she was slipping out of the hoist.
Inspector Kalay told SHP: “Mrs Evans’s death was a wholly preventable tragedy caused by unacceptable management failings on the part of Bupa.
“Managers of the nursing home failed to make an adequate assessment of the manual handling requirements for this elderly lady who was in their care. In particular, they did not give the carers sufficient information, instruction or training on how to use the sling properly.
“Working in a care home is a specialised job, which involves dealing with vulnerable people. Care homes must ensure that they have the correct training in place for all their employees.”
Bupa Care Homes (CFH Care) Ltd appeared at Wolverhampton Crown Court on 23 June and pleaded guilty to breaching s3(1) of the HSWA 1974. In addition to the fine it was ordered to pay £50,000 in costs.
Following the hearing, Bupa Care Homes regional director, Tim Seal, said: "This terrible accident should never have happened and we fully acknowledge that equipment was not used correctly, leading to Mrs Evan’s fall in 2007. Our nurses and carers carry out millions of hoist transfers every year and unfortunately, an error in this case led to tragic consequences. We are very sorry and would again like to offer our sincere condolences to her family.
“It was acknowledged by the judge that we have a good safety record and take the welfare of our residents extremely seriously. All our nurses and carers are fully trained and we now also have additional checks in place across all our homes to ensure that procedures are being followed.”
In January, SHP reported that Bupa Care Homes was ordered to pay £300,000 in fines and costs after an elderly patient died following safety failings at a nursing home in Birmingham. The patient, who suffered from Alzheimer’s Disease, was taken to her room to be put to bed, but, rather than helping her into bed, staff left her strapped in her wheelchair overnight. The next morning she was found dead on the floor, having been strangled by the lap-belt strap.
