Care Home Operator Fined After Death of Resident

A care home operator has been fined after the death of a vulnerable patient in one of its residences in Owestry, Shropshire.

Shrewsbury Crown Court heard how, on 15 February 2015 the resident of the care home in question was found at the bottom of a flight of stairs leading to the cellar with his wheelchair on top of him. The resident, 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.

An investigation by the Health and Safety Executive (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 the care home had not produced a risk assessment for access and use of the cellar and therefore had did not take account of the fact that the door opened inwards directly onto the stairs without a sufficient landing area.

The care home operator 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 this resident 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 care home employees, visitors and residents of a door which opened inward without sufficient landing.”

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