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January 30, 2009

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Care staff devised unsafe working practices

A man with severe learning disabilities and epilepsy drowned in a bath

at a Bishop Auckland care home after being left unsupervised by support

workers.

John Wood had been left on his own in the bathroom at the Lilac Lodge care home for several minutes because the solitary support worker present in the house at the time had left the bathroom to attend to other residents. The post mortem did not establish if Mr Wood had drowned as a direct result of an epileptic seizure, although this was regarded as a distinct possibility.

The HSE investigation into the incident, which occurred on 12 November 2006, found that no suitable and sufficient assessment had been carried out of the risks to the health and safety of Mr Wood during bathing. Mr Wood had suffered seizures in the bath on at least three previous occasions — twice in 2002 and once in 2005. Only one of these incidents was investigated by Durham County Council, which administered the care home as part of a supported housing scheme.

Despite these incidents, no suitable system of work had been devised and, as a result, the five support workers at the home developed their own working practices.

HSE inspector Richard Bishop, who led the investigation, told SHP: “This resulted in considerable variances in the way in which Mr Wood was bathed by the staff at Lilac Lodge, in terms of the level of supervision and the amount of time he would be left alone in the bath. They would also differ in terms of whether Mr Wood was, in fact, bathed or showered, and how deep the bath was run. Critically, most of these work methods were unsafe, in that Mr Wood would often be left unattended in the bath for significant periods of time.”

None of the support workers had received any specific safety training in relation to bathing or showering residents. Two members of staff were expected to be present at perceived ‘busier’ times of the day but, in practice, workers would often have to bath Mr Wood at times when they were working on their own. “Even when two support workers were present, they could still often leave John in the bathroom unattended, having never been instructed otherwise,” added the inspector.

The HSE laid charges against the council in September 2008. The case was heard first at Peterlee Magistrates’ Court in November last year, where the council entered a guilty plea to two charges — a breach of s3(1) of the HSWA 1974 for failing to protect those not in its employment; and a breach of reg. 3(1) of the MHSWR 1999 for failing to carry out a suitable and sufficient risk assessment.

The council was fined £30,000 plus 20,736 costs, on 23 January, after the magistrates referred the case to Durham Crown Court for sentencing.

In a statement issued to SHP, Rachael Shimmin, the council’s director of adult and community services, said: “We are all deeply saddened by, and truly regret, this tragic accident, and we would like to offer our sincerest sympathies to John Wood’s family and friends.”

Following the incident, the council undertook a review of the circumstances leading to Mr Wood’s death, and implemented an action plan to remedy shortfalls in practice and tighten internal management arrangements.

Ms Shimmin added: “The purpose of shared-living schemes is to promote privacy, dignity and independence but this may result in an increased likelihood of risks being encountered by an individual. . . The challenge in providing it is to achieve a balance between levels of care, supervision and support on one hand, and independence, autonomy and opportunity on the other.”

Summing up the case, Inspector Bishop said: “In health and social care, it is well known that, for many service users, bathing can be a significant area of risk, not just as regards drowning but also owing to other hazards, such as high water temperatures. Wherever there are doubts about a service-user’s ability to protect themselves, as was clearly the case with Mr Wood, it is essential that a risk assessment is made, using the findings of the assessment to ensure appropriate control measures are introduced.”

What makes us susceptible to burnout?

In this episode  of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.

We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.

stress
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