On 21 July 2013, a resident at the care home managed by Hill Care Ltd in Bakewell had been left in her room in her wheelchair for almost three hours, with no checks taking place, when she slipped down the wheelchair and died.
The home’s policy was to not leave residents in wheelchairs in their rooms at all but this was not followed. Due to poor communications at shift changeover, the resident was only found a number of hours after she had been left by a family member, by the oncoming nightshift when they carried out their nightly checks.
The HSE’s investigation found that Hill Care Ltd both failed to train staff in the proper use of specialised wheelchairs and to inform family and friends how to use the chair on trips out. The investigation also found the company failed to devise, implement or properly manage structured and effective systems assuring the whereabouts of patients is known and failed to ensure there was clear communication of such essential information at shift handovers.
Hill Care Limited of Saltergate, Chesterfield, pleaded Guilty to breaching section 3(1) of the Health and Safety at Work etc Act 1974, was fined £100,000 and ordered to pay £12,000 in costs.
Speaking after the hearing, HSE inspector Steve Shaw said: “This case highlights the need for companies to have in place a system to identify where residents are, and if they need attending to, after being taken out or moved around the home. This information should then be clearly communicated between staff at shift changeovers. Systems such as [this] are easy to implement and would have helped prevent an incident such as this from occurring.
“This case also highlights the need for suitable and sufficient training of all employees on specialised equipment used by residents and sufficient information to be passed to family and friends who may use this equipment when moving residents around the home or taking them out.”
