A care home operator in Scotland was fined £400,000 due to safety breaches resulting in the death of a resident. Susan Greens, 95, was found unsupervised outside her care home having suffered a fall and later passed away in the hospital. The Health and Safety Executive (HSE) investigation revealed that she had accessed an unsupervised courtyard via an unlocked door and was found on the floor with a head injury, after being outside for at least an hour.

Springfield Bank Care Home, operated by HC-One Ltd, is a purpose-built care home offering nursing and nursing dementia care. The organisation pleaded guilty to breaching section 3(1) and section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The HSE inspector stated that better safety measures could have prevented the tragedy.

The Greens family lodged complaints with the Care Inspectorate (the regulatory body for Scottish care services) alleging inadequate care and staff treatment during the incident. Inspectors upheld several complaints, citing failures to protect Susan, assess her injuries, and provide proper support during the emergency. They acknowledged staff incompetence and lack of skills in managing critical situations.

Following the incident, HC-One Ltd conducted a thorough safety review, implemented new door alarms, enhanced training procedures, and increased monitoring and supervision practices. 

Overall, the case highlights the critical importance of robust safety protocols in care settings, notably, the need for health and safety reviews to be conducted regularly alongside risk assessments. Simple measures, such as door alarms and window restrictors, can be important in mitigating the risk of safety incidents, especially for vulnerable service users who may be more prone to wandering and/or have a cognitive impairment. 

Further, ongoing staff training is essential to ensure that in emergencies, all are aware of the organisation’s protocol which reduces the risk of further harm to service users. 

Jackie Morris in our employment team outlined some practical steps providers can take to ensure staff are well-equipped when responding to emergencies following a similar incident. You can read his post here.