HSE WM/426/08 12 December 2008

Council fined after 90-year-old lady dies

The Health and Safety Executive (HSE) is warning health and social care organisations and other employers to ensure that they carry out suitable risk assessments to determine the safety of equipment used in everyday tasks.

This warning follows an incident that occurred in June 2007 outside the house of a 90-year-old lady. As a service user of the Wombourne Day Centre she was sitting in a wheelchair when it fell from the back of a vehicle operated by Staffordshire County Council. She suffered internal injuries and died 3 days later in Russell's Hall Hospital.

HSE’s investigation found that the wheelchair used at the time of the incident had defective brakes and there were no footrests fitted. It appeared that the wheelchair footrests were lost several years ago yet, despite their absence, the wheelchair continued to be used daily to transport service users.

No daily or weekly checks were carried out on this wheelchair as a matter of routine, despite the Council having legal duties. Combinations of tyre wear from several years' use, poor adjustment of brakes and lack of footrests all contributed to the incident. Following the accident the Council found other regularly-used wheelchairs with defects and of the 47 in use in 16 centres around Staffordshire six were found to have defects, including the brakes.

The investigation also found that Staffordshire County Council had no system to audit that procedures were in place for the necessary checks on the wheelchairs used in its transport vehicles to convey service users.

Staffordshire County Council was fined a total of £83,000 and ordered to pay costs of £21,000 at Stafford Crown Court, on 12th December,2008, after pleading guilty at an earlier Magistrates’ hearing on 31 July to breaching section 3(1) of the Health and Safety at Work etc Act 1974.

HSE’s investigating inspector Ian Williamson said: "Lack of maintenance, lack of routine safety checks and the absence of a system for the management of wheelchair safety were all major contributory factors.

"It is vital that equipment used in the working and care environment is maintained so that its performance does not deteriorate to such an extent that it puts people at unnecessary risk. The legal duty of care is very firmly vested in all employers to plan, organise, monitor and review procedures for checking equipment. It is easily foreseeable that brakes that have not been maintained over a period of time pose a serious risk to the safety of wheelchair users and others.

"A suitable risk assessment or a schedule of routine checks and maintenance, carried out by competent staff, should have identified, recorded and led to the correction of any defects.

"Staffordshire County Council failed in its duty by exposing day patients to such obvious risk. It is essential to ensure that all equipment, is not only regularly checked and maintained but that staff receive adequate information, instruction and training in the safe use of that equipment."

Notes to editors

1. Section 3(1) of the Health and Safety at Work etc Act 1974 states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety".
   In this instance, patients were the ‘persons not in employment’ who were put at risk by Staffordshire County Council’s failure to have a safe system of maintenance and routine safety checks in relation to wheelchairs.
2. Further information on managing risks in the healthcare sector can be found at http://www.hse.gov.uk/healthservices/index.htm

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