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January 20, 2011

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Strangled-patient investigation uncovers “shocking” safety management

Bupa Care Homes has been ordered to pay £300,000 in fines and costs after an elderly patient died following safety failings at a nursing home in Birmingham.

Bridgit O’Callaghan, 74, who was known as Vera, had been admitted to the Amberley Court Nursing Home in Edgbaston for temporary respite care. She was confined to a wheelchair and was suffering from the early stages of Alzheimer’s disease.

On 27 October 2005, Mrs O’Callaghan was taken to her room to be put to bed, but, rather than helping her into bed, staff left her strapped in her wheelchair overnight. The next morning a carer found her dead on the floor, having been strangled by the lap-belt strap.

Investigating HSE inspector Sarah Palfreyman described Mrs O’Callaghan’s death as a “shocking case of mismanagement” by Bupa. She added: “The managers of this, and indeed all care homes, have a duty of care to their residents. At the very least, they should be making sure that residents are comfortable and safe at night, not left in a wheelchair.”

Inspector Palfreyman’s investigation found a number of failings in Mrs O’Callaghan’s treatment, including: staff failing to carry out a proper risk assessment and care plan for her stay; a failure to communicate her needs to staff; failing to ensure she had a means to call for help; and no monitoring of whether night-time checks were carried out.

The investigation also revealed a catalogue of potential hazards that put residents at risk. These included the absence of window restraints; excessive water temperature in two bathrooms; failure to secure housekeeping rooms; tripping hazards and clutter in corridors; storing lifting slings over a handrail; a dirty shower and toilet; insufficient resources provided for maintenance; poor monitoring of the home’s management; and a lack of staff training.

Commenting on her findings, Inspector Palfreyman said: “There were some awful conditions for the elderly residents to live in and hazards that could easily have caused them serious injury. The home’s managers were not given appropriate monitoring or supervision and, as a result, the staff were not being properly trained, or monitored.
“Working in a care home is a specialised job and it’s vital that all employees have the correct training in place, which, in this instance, they did not.”

Following the incident the care-home operator was issued three Improvement Notices, which required it: to put in place proper health and safety management systems; to fit and repair adequate window restraints; and to train staff how to use lap belts safely so patients can’t slip.

Bupa Care Homes Ltd appeared at Birmingham Crown Court on 19 January and pleaded guilty on two charges of breaching s3(1) of the HSWA 1974. It was fined a total of £150,000 and ordered to pay the same amount in costs.

In mitigation, the company said it has completely reviewed its procedures for patient care at all of its homes. It has also replaced a number of staff at the Amberley Court Nursing Home, which included appointing a senior regional manager to take control of the home.

After the hearing, Bupa Care Services regional director, Tim Seal, said: “This was a wholly exceptional event that should never have happened. We said how deeply sorry we were to Mrs O’Callaghan’s family at the time and I would like to say that again now.

“The court accepted that Bupa is committed to ensuring safe working practices and that this tragedy was caused because a nurse and a carer did not follow our clear guidelines. But, as a responsible company, we have also accepted that there were failings in the way the home was being run in 2005.

“Those issues have been addressed, and this progress in key areas has been noted during a number of detailed monitoring visits and inspections that have take place since.”

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