10 Nov 2017

Community Safety and Licensing

Bupa Care Home Ltd fined following fatal fall at Stoke Bishop care home

Bupa Care Homes (ANS) Ltd has been fined following the death of an elderly resident at one of its care homes. The company pleaded guilty yesterday (9 November) to two offences under health and safety laws and was ordered to pay a total of £351,080. This includes a fine of £333,333 and £17,576 prosecution costs.

The case followed an incident on 6 June 2014 when a 90 year old resident of Druid Stoke Residential Care Home was fatally injured after falling on a flight of stairs and hitting her head. She died of her injuries in hospital the following day.

Cllr Helen Holland, Cabinet Member for adult social care, said: “This was a very sad incident and one that we hope will never be repeated. On behalf of the council we send again our deepest condolences to Mrs Davies’ family. I am glad that this case is concluded, although it cannot undo what has been done. People deserve to be safe and receive a high quality of care wherever they’re looked after, and every care provider needs to do all they can to meet – and exceed - the standards set out by the Care Quality Commission. Our Quality Assurance team work with care providers to advise them, and I understand that they have worked closely with Druid Stoke Care Home following the death of Mrs Davies.”

An investigation by Bristol City Council found that Mrs Ivy Davies had lived at the home for just over a year. She had a diagnosis of dementia and after suffering a broken hip in an earlier fall at the home she had been assessed as needing to be accompanied whenever she moved around with her Zimmer frame.

The investigation showed that on the morning of 6 June 2014 Mrs Davies was having her breakfast in the dining room downstairs while the care worker responsible for that area was also taking trays upstairs for other residents. While the care worker was upstairs Mrs Davies walked alone along the ground floor corridor and then through a fire exit door onto a staircase. When the care worker came back a short while afterwards she saw the Zimmer frame at the end of the corridor, and then found Mrs Davies lying on the staircase.

It appeared that Mrs Davies had started walking up the staircase, possibly in an attempt to find her room which was on the first floor, but had fallen backwards and hit her head on the wall of the stairwell. Staff looked after her until the ambulance arrived and she was taken to the BRI where she died the following day.

Further investigation showed that assessments had been carried out and recorded in Mrs Davies’ care plan but had not been put into place. There was no indication of how the limited number of staff at work would be able to ensure that she was accompanied whenever she moved. Her bedroom was on the first floor and she was known to occasionally set off up or down stairs by herself, with or without her Zimmer frame.

The fire exit staircase on which she fell was not intended for use by residents except in an emergency, but there were no controls over access to it, and its design was not suitable for elderly and frail residents who may have poor sight. The handrails were hard to grasp and the edges of the steps were not highlighted in a bright colour.

Following the incident a council Health and Safety Inspector carried out a full inspection and then served an Improvement Notice requiring works to remedy the range of slip and trip risks she found at the site, both indoors and in the garden. This was found to be complied with in October 2014 and a keypad control was put on the doors to all staircases not intended for general use by residents.

Bupa Care Homes (ANS) Ltd admitted breaching Section 3 of the Health and Safety at Work etc Act 1974 and also Regulation 6 (1) of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, which requires such injuries to be reported immediately. This accident was only reported to the council on 4 July 2014 after a Care Quality Commission inspector had visited and advised the manager that this was required.

The company was fined £333,333 for the breach of Section 3 with no separate penalty for the breach of Regulation 6. It was ordered to pay costs of £17,576 for the prosecution.

To request advice or information or to make a complaint about conditions in workplaces and residential care homes, call 0117 922 2500 or e-mail health.safety@bristol.gov.uk