NHS Trust fined after 87 year old suffers fatal injuries

Kent and Medway NHS Social Care Partnership Trust has been fined for safety failings after an 87 year old man suffered fatal injuries.

Maidstone Crown Court heard how the man, who was suffering from dementia, was being cared for at the Frank Lloyd Unit, Sittingbourne, by the Kent and Medway NHS Social Care Partnership Trust. On 9 April 2008, he was being bathed, slipped from the hoist and fell about three feet suffering serious injuries. He died the next day in Medway Maritime.

Following this reported incident, an investigation by the HSE found that (on 9 April 2008) that there was poor communication between the nursing staff and the agency care workers. It also found that the care plan was not clear and, in any case, was not shared with the agency carers. There was no consideration of the risk of using a bathroom in another ward which precluded any active supervision of the agency carers.

Kent and Medway NHS Social Care Partnership Trust, of Farm Villas, Hermitage Lane, Maidstone, was fined a total of £107,000 and ordered to pay a further £25,000 in costs after pleading guilty to breaches of Sections 3(1) of the Health and Safety at Work etc. Act 1974.

HSE inspector Jan Combs said, after the hearing:

“The combination of circumstances that allowed this accident to happen should never have been allowed to occur.

“This case has shown that it’s not enough to have well-intentioned management procedures if these are not followed through at ward level. There must be a robust mechanism to communicate care needs to all staff including temporary agency staff. Clear communication is an essential part of good management.”