An Essex hospital has been heavily criticised for risk-assessment failings and deficient communication procedures following the death of a severely disabled young man in its care.
Kyle Flack, 20, died at Basildon University Hospital on 12 October 2006 after his head became trapped between the bottom rail surrounding his bed and the edge of the bed itself. He died from asphyxiation.
Basildon and Thurrock University Hospitals NHS Foundation Trust was fined £50,000 plus £40,000 costs at Basildon Crown Court yesterday (8 June) for breaching s3(1) of the HSWA 1974 by failing to ensure the safety of patients in its care.
Mr Flack, from Stanford-le-Hope, suffered from cerebral palsy and was blind, deaf and quadriplegic. The court heard that he had been admitted to the hospital with a stomach complaint and was placed in a single room without one-to-one care and only monitored at irregular intervals.
During the night before he died, he was found several times lying diagonally in his bed and with his head wedged between the rails. He was repositioned twice by nurses but later, despite concerns raised by a passing cleaner, no action was taken.
The next morning Mr Flack was found lying with his head trapped between the bottom rail and the edge of the bed. Despite resuscitation attempts he could not be saved. Although 20 years old, Mr Flack had the body of a 12-year-old boy, yet he had been placed in an adult-sized bed. Had he been in a bed more suitable for his size he would have been physically unable to get his head through the bars.
In February, when the Trust admitted the breaches, Basildon Crown Court heard there had been a similar incident during an earlier stay at the hospital. On that occasion, the young man suffered bruising, swelling and a bleeding mouth after he forced his head part way through the rails. Despite this no assessment of his needs was carried out when he was admitted in 2006, and staff had no knowledge of the previous incident.
An investigation by the HSE found that the Trust had no systems in place on each ward for assessing the risk to patients from bed rails. People with cerebral palsy are known to be particularly at risk of entrapment and the issue was highlighted in Department of Health guidelines published in 2001.
The Trust’s practice for obtaining, recording and disseminating information about Kyle’s needs was found to be poor. There was no system in place to alert staff to Mr Flack’s particular needs or habits; instead staff were relied upon to remember him from previous visits, or to retrieve records to read through his past medical notes. There was no formal system for sharing knowledge of individual patients.
Speaking after the Trust was sentenced, HSE inspector Sue Matthews said: “This was an entirely preventable incident that resulted in the death of a vulnerable and much-loved young man. Simple measures should have been taken to prevent this from happening. This would have included a thorough bed-rail risk assessment being carried out by a qualified member of staff, with input from Kyle’s mother and reference to a previous bed-rail injury, which Kyle suffered at Basildon Hospital in 2005.
“The use of suitable bed-rails and bumpers, frequent monitoring of Kyle while the bedrails were in place, and proper record-keeping by staff would also have helped prevent this tragic death.”
In a statement issued after the sentence was handed down, Maggie Rogers, director of nursing at the Trust, said: “We fully accept and profoundly apologise for the mistakes made in the care of Kyle Flack. We have expressed our apologies and condolences to his family and friends and reiterated these publicly.
“The Trust fully accepts its failings. We indicated a guilty plea at the earliest opportunity and accept the court’s sentence. We were grateful that the judge stated he was quite satisfied that the Trust has since done everything it should have – and probably more – by way of remedial action.”
“In the years since Kyle’s tragic death, we have completely reviewed the care provided to patients with learning disabilities and have put in place many improvements. These include training for all staff, many changes to protocols and procedures, and over £1million of investment to re-equip the hospital with new beds and bed-related equipment.”
Mr Flack’s mother, Gill, said the sentence marked “the end of a long journey” for the family. She added: “When Kyle was in our lives we woke up and went to sleep to the sound of him laughing. He was full of life, the noisiest member of our family, and dearly loved by both his friends and the wider community.
“When you put your child into hospital, you expect him to be cared for and to pick him up once his treatment is over. There will never be closure for us as Kyle can never be replaced but, through the support of HSE, this result has helped us to feel that justice has finally been done.”
Concluded inspector Matthews: “Hospitals are subject to the same safety regulations as any other organisation and HSE will ensure that those who breach health and safety requirements, or fail in their responsibilities, are held to account.”
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