Archive for February, 2019

Care home knife wounds: NHS Oxleas Trust fined £300,000

Health and Safety Executive v NHS Oxleas Trust (2018) Central Criminal Court, December 20

Statutory reference: ss. 2 and 3 of the Health and Safety at Work, etc., Act 1974 (HSWA)

NHS Oxleas Trust has been fined following an incident in which two employees suffered serious stab injuries.

The facts

  • In July 2016 a health care assistant at the Bracton Centre, a medium secure forensic in Kent, was working in the Centre’s kitchen. A service user stabbed him repeatedly with a kitchen knife. He suffered stab wounds to his arms, abdomen and chest, which caused serious internal injuries.
  • A psychiatric nurse who shouted for the attack to stop was also stabbed multiple times.
  • Both victims continue to suffer pain, medical problems and psychological damage.
  • The Centre routinely received high risk patients but there was no patient-specific risk assessment which identified risks and measures required to control those risks before patients were admitted.
  • The use of knives was fundamentally unsafe. Employees were entering and exiting the kitchen several times as knives were in use. There were no instructions or control measures in place regarding kitchen knives.

The decision

The Trust was fined £300,000 plus £28,000 costs under ss. 2 and 3 of HSWA.

An HSE inspector commented after the case that the treatment of patients in medium secure units involved an inherent risk of violence and aggression. The Trust had a duty to ensure the safety of its staff and patients so far as was reasonably practicable.

Death of child in lift: £1.5 million fines


Health and Safety Executive v Synergy Housing Ltd and Orona Ltd (2019) Bournemouth Crown Court, January 15

Statutory reference: s.3 of the Health and Safety at Work, etc., Act 1974 (HSWA)

Two companies have been fined after a five-year old child was killed in a lift.

The facts

  • The family of Alexys Brown, aged five, lived in a property in Weymouth. The property had an internal lift used by her disabled brother.
  • The child entered the lift. She put her head through a hole in the vision panel. As the lift moved upwards, her head was stuck. She suffered fatal injuries.
  • Synergy Housing Ltd, the landlord of the property, had an agreement with Orona Ltd for the maintenance and repair of the lift.
  • In May 2015 an Orona engineer noted that the lift’s vision panel was damaged.
  • Tenants were not provided with safety critical information about the operation of the lift.
  • No risk assessment was carried out following the change of lift user when the child’s family moved in.
  • The damaged panel was not replaced.
  • The key switch used to control operation of the lift had been modified from factory installation to allow removal of the key in any position. The switch was in the on position with the key removed and could be operated at any time by anyone.
  • HSE guidance states that lifts should be inspected every six months. In this case, the lift was serviced only four times between 2009 and 2015 and had not been thoroughly examined since 2012.

The decision

  • Synergy Housing Ltd was fined £1 million plus £40,000 costs under s.3 of HSWA.
  • Orona Ltd was fined £533,000 plus £40,000 costs for the same offence.

An HSE inspector commented after the case that the companies had failed in their duties to put systems in place to ensure that the lift was kept safe. Safety-critical aspects of the use and maintenance of the lift were missed. Over a long period of time, the lift became more dangerous for the family to use.

Care home death: company fined £60,000

Crown Office and Procurator Fiscal Service v Kinning Park Care Home (Scotland) Ltd (2019) Glasgow Sheriff Court, February 14

Statutory reference: regulation 4 of the Provision and Use of Work Equipment Regulations 1998 (PUWER)

A Scottish care home has been fined following the death of a resident.

The facts

  • In September 2015 staff members at the Kinning Park Care Home were unable to find a resident.
  • The resident was found with a head injury at the bottom of a set of stairs in the home’s boiler room. The resident later died.
  • The boiler room door had a lock which was opened by key to allow staff access to the boiler room. There was a fault with the door closure mechanism and it did not always close automatically.

The decision

The care home company was fined £60,000 under regulation 4 of PUWER for failing to ensure that work equipment was constructed or adapted to be suitable for the purpose for which it is provided.