Another tragic death that could have been avoided
Posted on: 08/06/2016 By: Lee Rance
Care Company Bupa has been fined £400,000 following the death of a 91-year-old woman.
Josephine Millard was found dead after falling from her bed at the Beacon Edge Nursing Home in Penrith in 2013. She died from natural causes, but the firm admitted failing to ensure her safety and failing to give staff adequate safety training. The two charges were brought by the Health and Safety Executive.
At the hearing Bupa admitted breaching Section 3 (1) of the Health & Safety at Work etc. Act 1974 and Regulation 9 of the Provision and Use of Work Equipment Regulations 1998.
The HSE told the court that BUPA had failed to ensure it managed the risk of bedrails through appropriate assessment and review of bedrail arrangements, and failed to train staff in the assessment of and safe use of bedrails.
The use of bedrails is common in care homes to help prevent vulnerable residents from falling from bed, but they should to be used appropriately, and staff must be trained in both their use and the process of assessment to identify suitable measures to protect individual patients from falls.
The court was told the company had a policy on bedrail management but it was not fully implemented as staff were not trained and assessments not conducted or reviewed when required.
Furthermore, measures identified to protect the resident where not implemented correctly and increased checks on the resident were not carried out as instructed by a medical professional.
In a statement, BUPA apologised to the family of Mrs Millard.
We have worked very hard over the last two years delivering extra training and making a number of changes to improve the care our residents’ receive. This was recognised in the latest CQC inspection, which rated the home as good and compliant in all areas, finding that staff treated people with kindness and respect.
After the hearing, HSE Inspector Carol Forster said:
The need for adequate risk assessment and management of third party bedrails has been recognised in the healthcare sector for a number of years and guidance and advice has been published by the relevant bodies to this effect. Bedrails are used to protect vulnerable people from falling out of bed but each patient should be assessed individually and appropriate measures taken to protect them from falls from bed. Staff working with bedrails must be appropriately trained in the use of bedrails and in the patient assessment process. In this case there was a lack of appropriate assessment of the residents’ changing needs and review of the control measures in place to protect her. The measures that were in place were not used correctly in that the sensor pad which would have alerted staff to the resident’s being out of bed was not switched on. The company failed to comply with the expected standards in bedrail management and training and I hope this case will send a strong message to others with responsibilities for bedrail management.
The firm was also landed with costs totalling £15,000.
Until next time.