NHS Foundation Trust fined over patient death

Surrey and Borders Partnership NHS Foundation Trust has been fined for health and safety failings after a patient fell to his death.

The patient had been detained as an in-patient at Epsom Hospital when the incident occurred in May 2014.

Patient was in the courtyard with his mother while being observed by a nurse from inside the ward when he started to climb up onto the conservatory roof.

The nurse immediately ran into the courtyard but was unable to prevent him climbing over the roof. He then climbed up a 130-foot industrial chimney and after attempts to talk him down failed, he fell and sustained fatal injuries.
Fined £300,000 and costs of £16,769.00.

More>>  Here

Window restrictor overridden – death of elderly resident

A care home company has today been fined almost half a million pounds after an elderly resident fell from her first floor window and died.

Guildford Crown Court heard that the 87-year-old was staying at the Coppice Lea Nursing home in Surrey, owned and managed by Caring Homes Healthcare Group Limited. In the early hours of 3 October 2013, the woman fell about four metres through her window.

She was reported missing at 1am and found two hours later. She was pronounced dead at the scene.

Fined  £450,000 and ordered to pay costs of £14,762.44.


Note NASHiCS has produced a briefing note on
Falls from Windows – What do i have to do to?
download document  here

Care Home fined -failure to employ registered manager

Epsom care home fined £4000 for a persistent failure to employ a registered manager

CQC issued the fixed penalty notice to Epsom Lodge Care Homes Limited after inspectors found that a
registered manager was not employed – which is a legal obligation.
Inspections took place on the 8 April 2016 and the 19 September 2016 and the reports record that there was no registered manager in place.

CQC inspectors found that the home in Burgh Heath Road, Epsom, Surrey, had failed to have a registered manager from January 2016 until March 2017.

Epsom Lodge had told CQC that a manager had been employed since 1 February 2016 – although the manager’s application to register had been rejected because there were gaps in the information needed.

Subsequently CQC issued a fixed penalty notice, which the provider has accepted and paid.




Care home in York fined £50,000 over resident’s window jump

A YORK housing trust has beened ordered to pay £78,000 over a health and safety breach discovered during the investigation into the death of a resident at one of its homes.

It has also emerged that Joseph Rowntree Housing Trust (JRHT) had been warned about the safety of communal room windows at another of its homes, Lamel Beeches, in Heslington Road, York, two years before Dora Strickland, 90, jumped to her death through a second floor bedroom window at Red Lodge, New Earswick.

After the death, York Crown Court heard, the Trust unsuccessfully tried to overturn a City of York Council improvement notice forcing it to upgrade safety features for windows in residents’ windows at Red Lodge. The windows now have improved safety measures.

More details>> York press

More>> BBC


Care home fined after boy drowned in a disused quarry.

A Kettering based care home company has been fined after a 16-year-old boy drowned at a disused quarry. The two boys went into the water at the pits despite the no swimming signs.

One became trapped in weed on the bottom of the pit and drowned.
His body was recovered later.

An investigation by the HSE in July 2013 found the two residential support workers who accompanied the boys had very little experience and did not attempt to prevent the children entering the water.

No risk assessment was carried out prior to the trip and Castle Homes’ procedures were ineffective in ensuring the safety of the children while on trips outside of the home.

Castle Homes Ltd,  Kettering, was fined £80,000 and costs of £20,000.

More details>>


Care Worker Imprisoned after the Death of Service User

A former care worker at Springwood Day Centre, has been sentenced after the death of service user.

A group of Service Users from the day centre,had been on a trip to Kings Mill Reservoir.

The Carer, who at the time was supposed to be providing one to one supervision, lost sight of the Service user, who drowned when he suffered an epileptic seizure around the time that he fell into the reservoir.

A joint investigation by the HSE and Nottinghamshire Police found that the Carer spent a significant amount of time on her mobile phone instead of giving her full attention to the Service user while walking with him around the reservoir.

Sentenced to four months imprisonment.

More here>>


With the increase of use of both personal and work mobile phones

Has the organisation made sure all staff have instructions that personal phones must not be used whilst at work – written permission must be obtained if they are required (e.g. family member may require urgent contact etc) in which case this must be risk assessed…?
Manage the Access.




Care provider prosecuted after burns incident at care home

A care provider that failed in its duty to provide safe care and treatment has today been ordered to pay £24,600 in fines and costs.

A 79 year old resident fell against an uncovered radiator at Manor House Residential Home in Morden and received serious burns.

The registered provider partnership, pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to a resident at the home.

Debbie Ivanova, CQC’s Deputy Chief Inspector of Adult Social Care, said: “This incident was entirely avoidable.

More details of the incident