A HUDDERSFIELD care home has been fined £165,000 for a ‘blind spot’ in its health and safety which resulted in the death of a pensioner.
Elsie May Beals, 93, was found dead by staff at Aden Court Care Home in Moldgreen after she caught her neck on bed rails which had not been correctly fitted.
New Century Care Limited, who are responsible for the home, appeared at Leeds Crown Court yesterday after admitting breaching section 3 of the Health and Safety at Work Act.
The court heard how Mrs Beals had been put to bed by staff but was found dead in the early hours of April 24, 2010.
A statement submitted by Brian Mather, a senior adviser for the Medicines and Healthcare products Regulatory Agency (MHRA), revealed that the safety rails had been set too wide for the mattress, allowing Mrs Beals to drop into a void between the mattress and the headboard.
Prosecutor Sam Green told the court: "The reality appears to be that the staff at Aden Court had largely been left to their own devices, to do their inadequately-trained best to use and operate bed rails without manufacturer’s instructions and without any adequate system in place to identify associated risks.
"It would appear that it amounted to a serious and sustained oversight, or blind spot, in relation to risk."
The prosecution identified the following failings by the company which included:
None of Aden Court staff had received any training on the use of bed rails or the associated risk with them before the death of Mrs Beals.
Guidelines produced by the Medicines and Healthcare Regulatory Agency had also not been brought to their attention.
On two previous occasions Mrs Beals had injured her leg when it became lodged between the mattress and the rails and a ‘buffer zone’ had been plugged with a duvet. No further action was taken.
A company risk assessment for Mrs Beals addressed risk of trapping limbs but did not follow through with effective prevention.
Defending the company, Ben Compton QC said: "Despite the serious oversight, Aden House is a well run, happy and safe home for the elderly."