Two health trusts and a private healthcare contractor have been sentenced following the death of a severely disabled 10-year-old girl who died when she fell out of a hospital bed at her home, after a faulty rail gave way during an epileptic seizure.
Jade Norton who suffered from Rett Syndrome, epilepsy and scoliosis which affected her physical and mental abilities, became trapped between the mattress and the vinyl sheeting after a rail, which was supposed to prevent her falling out of the bed when she was having a seizure, failed.
NHS Litigation Services (in respect of Blackpool Primary Healthcare Trust and North Lancashire Primary Care Trusts) and Advantage Healthcare Ltd, now Interserve Care Ltd, were prosecuted following an investigation into the incident at Jade’s home in Blackpool, Lancashire in June 2011.
It was heard in court how Jade’s parents Amanda, 42, and Lee, 41, had reported the broken bed on five occasions in three months before her death.
The court was told of the “multiple failings” from the trusts and prosecutor Lisa Roberts, for the HSE, said the errors “went back four years.”
She said: “She was sleeping in a bed with rails that were blatantly not safe.
“She was unable to move once the bed had failed.”
Judge Stuart Baker said the risks were all “foreseen and preventable” and the breaches “contributed materially” to Jade’s death.
The court heard no remedial action was ever taken and risk assessments of the bed were not carried out, despite Jade being found in a similar position twice previously and her seizures worsening.
NHS Litigation Services (in respect of Blackpool Primary Healthcare Trust and North Lancashire Primary Care Trusts) was fined a total of £60,000 after pleading guilty to breaches of Section 3(1) of the Health and Safety at Work Act 1974 (£30,000) and Regulation 5 of the Management of Health and Safety at Work Regulations 1999 (£30,000), and ordered to pay costs.
Interserve Healthcare Ltd in respect of Advantage Healthcare Group Ltd was fined a total of £50,000 after pleading guilty to breaching Section 3 (1) of the Health and Safety at Work Act 1974 (£25,000) and Regulation 3 (1) (b) of the Management of Health and Safety at Work Regulations 1999 (£25,000) and ordered to pay costs.
HSE Inspector Mike Mullen said: “The failings that led to Jade’s untimely death could so easily have been avoided. Basic assessments and maintenance would have prevented this from happening.
“Existing policies for the use of bed rails failed to be implemented and as a result, Jade and her family were failed by the organisations entrusted with her care.”
Jade’s father said: “Judge Baker could have imposed a £500,000 fine but it would not have made a difference, it still wouldn’t bring my Jade back.”
He said he hoped the case would be a “massive wake-up call” for organisations.
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