On 15 February 2015 Michael Ibbetson, a care home resident, was found at the bottom of a flight of stairs with his wheelchair on top of him. Mr Ibbetson, who had one leg amputated at the knee, was able to operate his wheelchair alone and had days of confusion. He was last seen by the nurse on shift going into a lift by the cellar door to go to his room on the first floor. The care home was operated by Akari Care Ltd
Investigating, the HSE found that although the door to the cellar had a key pad latch and was fitted with a self-closing device, it opened onto the stairs so that the first step was directly behind the door. The handrail was fitted in such a way that it was not possible to have a good handhold along its length, and there was no hand rail at the top of the stairs due to the door opening.
The door was used daily by kitchen staff and the maintenance man. The investigation also found that Akari Care Ltd had not produced a risk assessment for access and use of the cellar and therefore did not take account of the fact that the door opened inwards directly onto the stairs without a sufficient landing area.
Akari Care Limited of Albion Street, Leeds, was found guilty of breaching Sections 2(1) and 3(1) of the Health and Safety at Work Act 1974 and has been fined £120,000 and ordered to pay costs of £41,997.48.
Speaking after the hearing, HSE inspector Stephen Shaw said: “This tragic incident could have been avoided.
“It is unlikely Mr Ibbetson would have known the key pad number to the door, therefore the door cannot have been properly closed and locked.
“In this case, the risk assessment should have identified the potential risks to both Akari Care employees, visitors and residents of a door which opened inward without sufficient landing.”
