Prosecutions

The patient, who suffered from Huntingdon's disease, was found unconscious on 3 June 2008 at the care home in Bamber Bridge, and died later that morning in hospital.

The care home which is one of the largest providers of palliative care in the UK, appeared in court after an investigation by the Health and Safety Executive (HSE) found the home failed to manage the risks associated with the equipment used on the patient’s bed.

As her condition made her prone to involuntary movements, a specialist cushioning system was used along with the bed rails. However, Preston Crown Court heard the equipment was not used correctly by staff, creating a risk.

The HSE investigation found the patient was able to knock her bed rail out of position because it was not the right size for her bed. This created a gap between her bed rail and mattress in which she became trapped and was unable to breathe.

Speaking after the hearing, the HSE Principal Inspector on the case said:

"A mother has lost her life because of a systemic failure on the part of the care home.

"Because the home was oblivious to the risks associated with this kind of equipment, they had no proper risk assessments in place. The maintenance of the equipment was also poor and staff were not trained to spot any problems which could have arisen in this case.

"I would urge care providers to carry out regular risk assessments on all their equipment to make sure the way it is being used is fit for purpose and continues to meet the needs of residents."

The company pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974 after it failed to manage the risks associated with the use of bedrails. It was ordered to pay £35,000 towards the cost of the prosecution in addition to the fine on 27 June 2011.