A care home in Wales has been ordered to pay more than £100,000 in fines and costs after an elderly resident was killed when he fell 12 feet out of a window.
Stanley Tilston, 79, suffered from dementia and was a resident at Plas Rhosnesi Nursing Home in Wrexham. On 26 May 2008, he told his son that he had managed to bypass the window restrictor in his room on the first floor of the home, and he intended to escape out of the window. His son told staff about the plan and they locked the window.
Two days later a nurse saw Mr Tilston twisting a coat hanger in the window restrictor’s chain. This caused the chain to break, but he was unable to open the window as it was still locked. A maintenance man repaired the chain but then left the window open to filter out a smell in the room.
On 1 June 2008, Mr Tilston was found lying in a flowerbed outside the building. He had managed to twist the restrictor chain with an unidentified object until it snapped. He then opened the window, which had been left unlocked, and when he tried to escape he fell out of the window and landed on the ground 12 feet below. He died in hospital four days later from serious head injuries.
The HSE issued an Improvement Notice to the home’s management company, Care Homes Wrexham Ltd, on 11 June 2008. The notice required the home to install window restrictors that couldn’t be tampered with by patients.
HSE inspector Sarah Baldwin-Jones told SHP that the care home had failed to take suitable steps to protect Mr Tilston. During her investigation she learned that there was a vacant room on the ground floor where Mr Tilston could have been relocated.
“This incident was entirely avoidable,” said the inspector. “The chain window restrictors fitted at the home were unsuitable because they were not robust and could easily be defeated.
“Care Homes Wrexham identified this important safety issue in 2007, when they issued a maintenance manual to all their care homes, which said chain restrictors should not be used. They should have fitted window restrictors that could not be easily defeated and moved Mr Tilston to a ground-floor room. This was not done.”
Care Homes Wrexham, which was formerly known as Hallmark Healthcare (Wrexham) Ltd, appeared at Chester Crown Court on 27 January on s3(1) of the HSWA 1974. It was fined £66,000 and ordered to pay £43,287 in costs.
In mitigation, the firm said the maintenance worker was largely to blame, as he had left the window unlocked. But it accepted that the restrictors were not suitable, as patients could overcome them. The company has subsequently sold the care home but has put robust management systems in place to risk-assess all of its other homes.
In 2004, Hallmark Healthcare (Wrexham) Ltd pleaded guilty to breaching s3(1) of the HSWA 1974 after a resident at Plas Rhosnesi died from drinking dishwasher fluid. The company was fined £40,000, plus £6000 in costs.
