Care home fined after resident's fatal fall from window

Date:

27 January 2012

The owners of a Wrexham care home have been sentenced after an elderly resident defeated the window restrictor of his first floor bedroom and fell 12ft to the ground below.

Stanley Tilston, 79, suffered from dementia and was a resident at Plas Rhosnesi Nursing Home on Cefn Road in Wrexham. On the morning of 1 June 2008, he was found lying on the ground outside with serious head injuries. He died in hospital a few days later.

Chester Crown Court heard that Plas Rhosnesni specialised in the care of elderly and mentally infirm residents. Mr Tilston had told staff and his family that he had wanted to leave and repeatedly tried to break open the window's chain restrictor, which he succeeded in doing on two separate occasions.

A week before the incident, Mr Tilston's son visited the home and reported that his father had broken the restrictor and was planning to leave the home. However, staff failed to move his father to a vacant ground floor room.

A Health and Safety Executive (HSE) investigation found that the company had failed to complete a risk assessment on the risk of residents falling from windows, and failed to implement and review its window restrictor policy.

Previously known as Hallmark Healthcare (Wrexham) Ltd, Care Homes Wrexham Ltd. of Woodbank Crescent, Radford Way, Billericay pleaded guilty to a breach of Section 3 (1) of the Health and Safety at Work etc Act 1974.

It was fined £66,000 and ordered to pay £43,287 in costs.

After the hearing, HSE Inspector, Sarah Baldwin-Jones, said:

"This incident was entirely avoidable. The chain window restrictors fitted at the home were unsuitable because they were not robust and could easily be defeated.

"Hallmark Healthcare Ltd identified this important safety issue in 2007, when they issued a maintenance manual to all their care homes, which said chain restrictors should not be used. They should have fitted window restrictors that could not be easily defeated and moved Mr Tilston to a ground floor room. This was not done.

"Sadly, in the nursing and care home sector, this is a far too common cause of injury and death. Homes that care for confused and vulnerable persons should ensure that adequate training is provided to assist employees recognise this hazard. Homes need to conduct regular monitoring of window restrictors and have a system of review for any damage identified. These necessary actions would help reduce the likelihood of further tragedies like Mr Tilston's."

Further information on window safety in the care sector can be found on the HSE website at http://www.hse.gov.uk/healthservices/falls-windows.htm

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. The company pleaded guilty to a breach of section 3 (1) of the Health and Safety at Work etc Act 1974 which 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."
3. 3. HSE news releases are available at www.hse.gov.uk/press.

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