A jury at Glasgow Sheriff Court reached a unanimous verdict finding a Scottish care provider, guilty of health and safety breaches which lead to the death of one of their residents.
The 59-year-old resident had severe learning difficulties and was considered a vulnerable adult. The resident sadly drowned in a bath at night. The care provider was found guilty of charges under section 3 of the Health and Safety at Work (etc) Act 1974 of failings including carrying out a suitable and sufficient risk assessment to identify the resident’s needs. The care provider was fined £450,000.
Failings by the care provider
The resident was able to run a bath sometime between 1am and 7am on the night she died. A baby monitor had been supplied by the care provider to alert the support workers if the resident left her bed throughout the night. However, the use of a baby monitor was insufficient and ineffective as the resident was light on her feet and failed to alert support staff to her movements during the night. Concerns had been raised by staff previously, but the care provider had failed to consider other appropriate measures, such as pressure mats or door sensors.
Severe staff shortages and lack of awareness and understanding of the resident’s needs were found to materially contribute to her death. Four different service users, in four separate flats, were being supported by two support workers, one of which was on their first shift. They failed to hear that the resident was out of bed. The water to the resident’s flat should have been isolated, however, neither of the support workers knew how to do this. Further, it was found that the two support workers were not familiar with the resident despite being put in charge of her overnight care.
Following an investigation by the HSE, further failings were identified:
- The care provider had failed to carry out a suitable and sufficient assessment to identify the resident’s needs. Thus, the appropriate measures required to ensure her safety prior to becoming a resident were not put in place.
- Staff had not been given instruction from the care provider on how to carry out the appropriate checks on residents under their care.
- There was no check sheet which covered all relevant information relating to the resident’s care
- There was no suitable and reliable equipment to alert staff to the resident’s movements within the flat.
Sentencing
Commenting on the sentence, the Head of the Health and Safety Investigation Unit of the Crown Office and Procurator Fiscal Service, Alistair Duncan, said:
“This tragic incident could have been prevented had suitable and sufficient measures been put in place.
“Hopefully this prosecution and the sentence will serve to highlight to other similar organisations that failure to fulfil their health and safety obligations can have tragic consequences and that they will be held to account for their failings."
For care providers the case emphasises the onerous duties on them and potentially significant costs of getting things wrong. At a time when the care sector is under huge pressure, coming out of the pandemic, and facing immense challenges regarding resourcing and experienced workers, the risks are considerable. Please get in touch if you would like to discuss how we can help.
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