Health and Safety Failings – NHS Trust Fined After Man Fatally Injured

NHS Trust Fined After Man Fatally Injured

Key Facts

• NHS Trust prosecuted after 87 year old man suffered fatal injuries
• He fell three feet when he slipped from a hoist whilst being bathed, and died the next day
• The NHS Trust was fined £107,000 plus costs

The Case

An HSE investigation was launched into the safety practices of an NHS Trust after an 87-year-old man suffered fatal injuries whilst in their care.

The man suffered dementia and was being cared for at a social care unit of the NHS Trust. In April 2008, he was being bathed when he slipped from the hoist and fell three feet. He sustained serious injuries and died the next day.

The subsequent HSE investigation found that there was a poor level of communication between nursing staff and agency care workers, and that the proposed care plan was not clear and was not shared with agency carers. No consideration had been given to the risk of using a bathroom in another ward, precluding any active supervision of the agency carers.

The case was heard at Maidstone Crown Court where the NHS trust pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. They were fined a total of £107,000 plus costs of £25,000.

What the HSE had to say

Speaking after the hearing, HSE inspector Jan Combs said:

‘The combination of circumstances that allowed this accident to happen should never have been allowed to occur.

This case has shown that it’s not enough to have well-intentioned management procedures if these are not followed through at ward level. There must be a robust mechanism to communicate care needs to all staff including temporary agency staff. Clear communication is an essential part of good management.’

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