“Dangerous” restraint methods led to patient’s death

A care-home resident died after being physically restrained in an “inappropriate and dangerous” fashion by untrained staff, a court heard.

Anthony Pinder, 42, was one of a dozen residents at the Old Vicarage nursing home, operated by Health and Care Services (UK) Ltd, in Stallingborough, near Grimsby. He had learning and behavioural issues and was prone to bouts of self-harm and violence towards others. Consequently, from time to time, he had to be physically restrained.

On 1 October 2004, he was showing signs of self-harm and staff felt that his behaviour could lead to more violent actions. They decided to lower him to the floor and restrain him face down in a courtyard outside his room.

A nurse injected Anthony with a tranquiliser, but this appeared to have little effect and he began to struggle. Two staff reacted by holding him down, while a third straddled him – a situation that continued for around 90 minutes.

When it was deemed that he had calmed down, he was released and crawled unaided to his room. Staff then heard sounds suggesting that Anthony was self-harming. On observation, they saw him slapping his face and banging his head but chose not to intervene.

Staff continued to monitor him but on the last occasion found him lying on the floor surrounded by vomit. A paramedic was called and confirmed that Anthony had died. Later medical investigation suggested the probable cause of death was a heart attack.

A joint Police and HSE investigation found that the care home’s senior management had been told by the Commission for Social Care Inspection (CSCI) to train staff in safe-restraint techniques just five months prior to Anthony’s death, and had promised in writing that improvements would be made.

However, the investigation found that no such training was given, even in the immediate aftermath of Anthony’s death. The care home’s failure to act in this regard prompted HSE inspector Brian Fotheringham to issue a deferred Prohibition Notice on 28 October, which gave the home’s senior management fewer than 21 days (the usual timeframe to comply with an Improvement Notice) to ensure that staff were sufficiently trained.

Health and Care Services (UK) Ltd complied with the notice but, according to Inspector Fotheringham, had it not done so, the care home would effectively have been shut down.

During the case, an expert witness for the HSE told the court that the measures used to control Anthony were “poor, inappropriate and dangerous”, and confirmed that they would have played a major part in causing his death. Inspector Fotheringham said the defence did not contest this theory.

Health and Care Home Services (UK), part of the Craegmoor group, pleaded guilty before magistrates to a breach of s3(1) of the HSWA 1974. It was sentenced on 21 December at Leeds Crown Court and ordered to pay a fine of £80,000, plus £40,823 in costs. No blame was attached to the staff involved in restraining Anthony, who were doing what they felt was necessary under difficult circumstances.

Inspector Fotheringham told SHP that at the time of the incident there was a range of known recognised techniques for safe physical-restraint of patients. He described the approach adopted by staff of straddling Anthony as “extremely dangerous” and something that “shouldn’t take place”, as “it is quite clear that there is still pressure put on the person – for example, their lungs and the small of the back”. The practice was even more dangerous because of the length of time it went on for, he added.

He also pointed out that there should have been a minimum of four people involved in the restraint, with one cradling the head of the patient as a means of protection.

In mitigation, the company said it had entered an early guilty plea and pointed out that its board of directors has almost entirely changed since the incident. It said it had no previous offences and trained staff in safe-restraint techniques following Anthony’s death.

However, Inspector Fotheringham said the company’s failure to act on concerns raised by the CSCI prior to the incident, and immediately after the fatality, was an aggravating feature.

He said: “It is shameful that even after Anthony’s death the company did not train the staff. This was only done after I forced the issue by serving an enforcement notice shortly after commencing my investigation.

“The company says that steps have been taken to prevent a repeat of this incident. I hope Anthony’s tragic and untimely death, and the subsequent prosecution, send an important message to all care-sector companies.”

In a statement, which followed the sentencing, Anthony’s family said: “The failings that came to light during the prosecution are deeply shocking, and the blame in our eyes lies firmly at the door of senior management, who failed to provide training in safe-restraint techniques for the staff at the home. We have no grievance with the duty staff directly involved, who were doing their best in extremely testing circumstances, and who frankly didn’t know any better.”