A resident at Maesbrook, who was of full capacity but had suffered a stroke prior to admittance, was being showered when she slid from a shower / commode chair as she leant forward so that a carer could wash her back and shoulders in September 2014.
When the resident slid from the chair, she landed in the sitting position. The only outward sign of injury was a small laceration to her left elbow and no other complaints made. During the evening, the resident began to complain of pain in her right knee. As a consequence, her GP was called and a subsequent x-ray revealed a fracture to her left hip. Surgery was considered but declined. On her return to the care home, the resident was well for a week but then deteriorated very quickly and died shortly thereafter. The cause of death was recorded as 1a) cardiorespiratory failure; 1b) fractured neck of left femur; and 1c) fall.
There was a care plan, risk assessment including showering and all carers had been adequately trained in manual handling, aids and equipment.
Unfortunately, the risk assessment, although adequate, did stipulate that two carers should be required when showering took place. The risk assessment was open to misinterpretation and accepted by the HSE’s own expert as a poor clinical decision for one carer to attend when the shower / commode chair was utilised rather than a recliner chair.
The HSE chose to prosecute the care home under section 3(1) of the HSWA 1974. Given that the risk assessment required 2 carers to be in the shower room to reduce the risk of falling, and was open to misinterpretation, a guilty plea was entered.
Both in the HSE’s written documentation and before the court, a starting point of £160,000 was argued on the basis of ‘high’ culpability, Level A seriousness of harm risked and ‘high’ likelihood category 1. The care home was a ‘micro’ company with a turnover of under £2 million.
It was argued for the care home that culpability was ‘medium’ given that there was an adequate risk assessment and care plan in place which was not properly implemented. Further, that whilst it was easy to submit Level A, death was not a realistic category in terms of seriousness of harm risked in the circumstances; if it was, ‘likelihood’ would be no higher than ‘medium’, category 2.
The learned Judge accepted the defendant’s submissions and accepted a £30,000 starting point, reducing it to £20,000 for the early plea.