Trust sentenced over bed rail death of disabled man

Date:

8 June 2010

Release No:

HSE-E-10

The hospital where a young man with cerebral palsy died after his head became entangled in bedrails was sentenced today (Tuesday).

Basildon and Thurrock University Hospitals NHS Foundation Trust was fined £50,000 following the tragic death in its care of a severely-disabled young man who was described as being 'full of life' and a 'people magnet'.

Kyle Flack died at Basildon University Hospital early on 12 October 2006 after his head became trapped between the bottom rail surrounding his bed and the edge of the bed itself. He died from asphyxiation.

Though 20-years-old, Kyle had the body of a 12-year-old boy. He was blind, deaf, quadriplegic and had cerebral palsy.

He had been admitted to Basildon with a stomach complaint. During the night before he died, he was found several times lying diagonally in his bed and with his head wedged between the rails.

He was repositioned twice by nurses but later, despite concerns raised by a passing cleaner, no action was taken.

At around 8.20am Kyle was found lying with his head trapped between the bottom rail and the edge of the bed. Despite resuscitation attempts he could not be saved.

In February when the Trust admitted the breaches, Basildon Crown Court heard there had been a similar incident during an earlier stay at the hospital. Kyle had suffered bruising, swelling and a bleeding mouth after he forced his head part way through the rails.

Yet despite this no assessment of his needs was carried out when he was admitted in 2006 and staff had no knowledge of the previous incident. Kyle was placed in a single room without one-to-one care and only monitored at irregular intervals.

Investigations by HSE found the Trust had no systems in place on each ward for assessing the risk to patients from bed rails. People with cerebral palsy are known to be particularly at risk of entrapment and the issue was highlighted in Department for Health guidelines published in 2001.

The Trust's practice for obtaining, recording and disseminating information about Kyle's needs was found to be poor. Staff did not formally share knowledge of individual patients.

There was no system in place to alert staff to his particular needs or habits, instead staff were relied upon to remember him from previous visits or to retrieve records to read through his past medical notes.

Despite Kyle's size he was placed in a bed with adult spacing bed rails. Had the rails been suitable for Kyle it would not have been physically possible for him to get his head through any gap.

The NHS Foundation Trust was sentenced after it admitted failing to ensure the health and safety of patients in its care, breaching Section 3(1) of the Health and Safety at Work etc Act 1974. It was fined £50,000 and ordered to pay £40,000 in costs.

Kyle's mother Gill Flack said: "When Kyle was in our lives we woke up and went to sleep to the sound of him laughing. He was full of life, the noisiest member of our family, and dearly loved by both his friends and the wider community. When we were out with Kyle, he was a real people-magnet: his huge smile drew people to him. He loved life and lived it to his full capacity.

"When you put your child into hospital, you expect him to be cared for and to pick him up once his treatment is over. There will never be closure for us as Kyle can never be replaced but through the support of HSE, this result has helped us to feel that justice has finally been done. Today marks the end of a long journey."

HSE Inspector Sue Matthews said: "This was an entirely preventable incident that resulted in the death of a vulnerable and much-loved young man.

"Simple measures should have been taken to prevent this from happening. This would have included a thorough bedrail risk assessment being carried out by a qualified member of staff, with input from Kyle's mother and reference to a previous bedrail injury which Kyle suffered at Basildon Hospital in 2005.

"The use of suitable bedrails and bumpers, frequent monitoring of Kyle while the bedrails were in place and proper recordkeeping by staff would also have helped prevent this tragic death.

"Hospitals are subject to the same safety regulations as any other organisation and HSE will ensure that those who breach health and safety requirements, or fail in their responsibilities, are held to account."

A video of Gill Flack speaking about the death of her son can be viewed at http://www.hse.gov.uk/press/2010/kyleflack.htm

Photos of Kyle Flack will be available to journalists on request.

Notes to editors

1. HSE is Britain's national regulator for workplace safety and health. It aims to reduce injuries and illness in the workplace.
2. Section 3(1) of the Health & 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 risk to their health & safety."

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