Care Provider Prosecuted after Death of 38 year old

The care provider Castlebeck Care (Teesside) Ltd has been fined £100,000 after a patient died while being restrained using an unauthorised technique at a Nottinghamshire mental health hospital.

Derek Lovegrove was a 38 year old gentleman who had severe mental impairments, was registered blind, had 75% deafness in both ears and had limited communication skills.

Mr Lovegrove suffered a cardiac arrest at Cedar Vale, East Bridgford a 16 bedded nurse-led facility for adults with very challenging behaviours in July 2006.

Nottingham Crown Court was told during the two day hearing that minutes before his death Mr Lovegrove had been restrained for a short period of time by three support workers in the corridor after making a grab for two of them. After this event staff took him back to his room to avoid further incidents. One member of staff went to the kitchen whilst one stayed in the corridor and the other remained in the room with Mr Lovegrove.

Mr Lovegrove made a grab for the lone member of staff in his room, at which point the member of staff in the corridor entered the room taking hold of Mr Lovegrove arms to free their colleague.

Soon after staff realised that Mr Lovegrove was not breathing and dialled for medical assistance as well as administrating CPR. Paramedics pronounced Mr Lovegrove dead on the scene.

The Health and Safety Executive’s (HSE) investigation found the level of supervision and observation granted Mr Lovegrove was inadequate and not in accordance with his care plan. This stated that Mr Lovegrove should have 2:1 observation which was not in place immediately before his death.

Principal Inspector Frank Lomas from the HSE said “The failings of Castlebeck Care Ltd (now in administration) are substantial. They fell far below required standards of care. At the time of this tragic incident the breaches were relatively long-standing and had been the subject of specific warnings which had not been acted upon.”

“There was a failure to implement specific recommendations relating to the management of Mr Lovegrove’s behaviour made in a report in September 2005 and a failure to implement requirements and recommendations made by the Healthcare Commission following a visit in February 2006.”

He went on to say “The support worker should not have been left alone with Mr Lovegrove. If another member of staff had been observing as required by the care plan, it would have been less likely that events would have unfolded in the way they did. Consequently this would have reduced the risk to Mr Lovegrove and staff.”

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