Training failures led to patient death

Date:

21 December 2010

Release No:

YH/214/10

A care home operator was today fined £80,000 for serious training failures following the death of a patient as a result of "inappropriate and dangerous" restraint techniques.

Forty-two year-old Anthony Pinder, who had learning and behavioural issues, was physically restrained for around 90 minutes by staff at the Old Vicarage nursing home in Stallingborough, near Grimsby, on 1 October 2004. He was eventually released and crawled unaided to his room, but was found dead a short time later.

Leeds Crown Court heard that Health and Care Services (UK) Limited, part of the Craegmoor group, failed to ensure staff were adequately trained to carry out the safe physical restraint of residents.

The measures used to control Mr Pinder were described as "poor, inappropriate and dangerous" during the case, although those engaged in the restraint were not blamed because the court heard they were simply doing what they felt was necessary under difficult circumstances. The failure to train staff in safe restraint techniques rested with management.

The Commission for Social Care Inspectorate highlighted an urgent need for safe restraint training just five months prior to Mr Pinder's death, which prompted a written promise from senior management at Health and Care Services that improvements would be made.

However, the investigation found that no such training was given. The company therefore failed to comply with a regulatory requirement, and failed to take all reasonably practicable steps to protect patients at the Old Vicarage - a breach of section 3(1) of the Health and Safety at Work Act 1974.

In addition to the £80,000 fine for pleading guilty to the breach, Health and Care Services (UK) Limited was also ordered to pay £40,823 in costs.

Following the conclusion of the case HSE Inspector Brian Fotheringham said:

"Anthony Pinder was a vulnerable person whose death was entirely avoidable. Health and Care Services (UK) Ltd position themselves as a market leading specialist care provider through Craegmoor, and Anthony and his family had a right to expect that he would be properly cared for. But they were badly let down.

"Senior management knew that staff at the Old Vicarage often had to physically intervene and restrain residents, but they failed to ensure that staff were trained in appropriate and safe restraint techniques.

"This failure is inexcusable given that this lack of training had been drawn to the attention of the company following an inspection of the home by the Commission for Social Care Inspection five months before Anthony's death. Despite the fact that the Commission produced a report requiring this training to be provided, it was not delivered.

"It is shameful that even after Anthony's death the company did not train the staff. This was only done after I forced the issue by serving an enforcement notice shortly after commencing my investigation."

He added:

"The company says that steps have been taken to prevent a repeat of this incident. I hope Anthony's tragic and untimely death and the subsequent prosecution, sends an important message to all care sector companies."

Notes to editors

1. The Health and Safety Executive is Britain's national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
2. 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."

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