The Little Book of Health and Safety Horrors Part 3: care homes


Death of resident

Caring Homes Healthcare Group Ltd, the owner and manager of the Coppice Lea Nursing Home in Surrey, was fined £450,000 in 2017 after the death of a resident. In October 2013 an 87-year old woman was a resident at the home. She fell four metres through her window, suffering fatal injuries. The window restrictor in place was easily overridden and was not fit for purpose. All windows which are large enough for people to fall through should be restrained sufficiently to prevent falls. The benchmark of 100 mm should only be allowed to disengage using a special tool or key.

Bedrail failures

At the Beacon Edge Specialist Nursing Home in Penrith, Cumbria, BUPA Care Homes (CFC Homes) Ltd failed to ensure that it managed the risk of bedrails through appropriate assessment and review of bedrail arrangements, and failed to train staff in the assessment of and safe use of bedrails. The use of bedrails is common in care homes to help prevent vulnerable residents from falling from bed, but they should to be used appropriately, and staff must be trained in both their use and the process of assessment to identify suitable measures to protect individual patients from falls.

The court was told the company had a policy on bedrail management but it was not fully implemented as staff were not trained and assessments not conducted or reviewed when required.The case related to the management of bedrails in relation to a vulnerable resident who died at the home. The company failed to ensure the patient’s bedrail assessment was suitable and sufficient, reviewed following falls and deterioration in health and that staff were trained in bedrail risk assessment.The reviews of the bedrail assessment should have identified further measures to prevent the risk of falls, but staff that carried out the initial assessment and reviews were not adequately trained. Furthermore, measures identified to protect the resident where not implemented correctly and increased checks on the resident were not carried out as instructed by a medical professional.

Nursing home death

In November 2012 Patrick Foale, aged 75, was living at the Redmount Nursing Home in Devon. He fell down a flight of stairs in his wheelchair when he accessed a staircase after a fire door had been left open. He suffered fatal injuries. Foale spent much of his time in his own room on the first floor of the nursing home. He was capable of moving freely around the home in his wheelchair. The nursing home was aware that he had deteriorating eyesight and had been suffering periods of disorientation.The nursing home had failed to carry out a suitable risk assessment for him, had neglected to make provision for his deteriorating eyesight and di not act on his apparent disorientation.

Death from drowning

In July 2013 two boys who were residents at the Castle Lodge Care home near Ely were taken on a day trip to a country park near Kings Lynn, Norfolk.The park is a disused sand quarry with flooded pits. The boys went into the water despite no swimming signs. One, aged 16, became trapped in weed and drowned.No risk assessment had been carried out and the company’s procedures were ineffective in ensuring the safety of the children while on trips outside the home.

Care home death

In May 2012 Walter Powley, aged 85, was admitted to Western Park View, a care home, after his family was advised that he could not be safely left at home because of his risk of falling. Powley fell in his room at the home. He was trapped between a wardrobe and a radiator. He suffered serious burns to his legs from the radiator pipe and valves. The injuries were fatal. The pipes and valves were not covered and had temperatures of 73 degrees centigrade.The company which owned the care home was aware that the deceased was at risk of falls and injury and that staff should be vigilant. It had failed to assess the risks in his room and had not taken appropriate action to control and manage the risks.

Care home scalding

In December 2008 Paul Cundy was living in a care home in St Austell, Cornwall. Comhome provided housing for vulnerable people and Solor provided care staff for the home Cundy needed physical help with all aspects of his daily life. He was lowered into a bath by a care worker, using a hoist. He was so severely scalded that his skin was left hanging from his body. He was hospitalised for four weeks. There was no thermostatic mixing valve (TMV) fitted to the bath. This would have regulated the water temperature to below 44 degrees centigrade. Four internal maintenance reports had stated that the TMV was not functioning and identified it as high risk because the water from the hot tap was at 60 degrees.    Cundy’s care plan, drawn up by Solor, did not refer to the risk of scalding and there was no system to ensure that care workers had read the plan.


Care home window death

In November 2010 Olga Llewellyn, a 92-year old resident at the home, suffered fatal injuries when she fell from her bedroom window. All the windows at the home were fitted with the same type of window restrictors. These were unsuitable because they could be easily overridden and the windows opened wide.Between 2005 and 2010 there were 21 fatal accidents from falls from windows.


Death of dementia sufferer

Kenneth Terrey, a dementia sufferer aged 74, was a resident at the Paternoster House Care House in Essex.In March 2011 Terrey tried to leave the dementia unit. He climbed out of a window and fell to the ground. He suffered fatal injuries. At the time of the incident, a window restrictor, which would have prevented the window opening fully, was not working. Staff at the home had not been properly trained in how to carry out proper window safety checks and no window management safety system was in place.

Care home death

In August 2012 Beatrice Morgan, aged 88, a resident of the Greencroft Nursing Home in Queensferry,  Deeside who was unable to walk, was lowered into a bath using a hoist. She cried out when she touched the water and suffered nine per cent burns from the scalding water. She later died from her injuries. The temperature of the water was not properly controlled to prevent it exceeding 44 degrees Celsius. Mixing valves had been fitted to control the temperature but they had not been properly maintained. Staff at the home had been instructed to check the temperature of bath water with a thermometer but no checks were made by management to ensure that this was done. The company had failed to adequately assess the risks of using hot water and had failed to provide sufficient training, instruction and supervision.


Care home injury: fall from window

In December 2012 a 63-year old man, a resident of the Nada Residential and Nursing Home in Manchester, suffering from dementia, was found below his bedroom window suffering from multiple fractures. He told staff that he wanted to get some fresh air. The risk of residents falling from open windows was well known in the care home sector. The windows should have been fitted with restrictors to prevent them opening more than ten centimetres. The care home had failed to properly assess the risk of residents falling from windows and had not taken suitable action to prevent this happening.


Care home scalding in bath

In August 2013 Nicola Jones, a resident of a care home in Bathgate, was given a bath by Sharon Dunlop, a care support worker. Dunlop failed to check the temperature of the water. Ms Jones was scalded. She suffered 40 percent burns.  She required major surgery and now has to use a wheelchair. Employees were supposed to check the water temperature before a service user bathed, and to make a record of this check. The company did not provide written instructions confirming this.

An HSE inspector is reported to have commented after the case that the injuries had been easily preventable by the simple act of checking the water temperature. Employers should ensure that their staff are provided with a thermometer and training in the safety aspects of bathing or showering people for whom they provide personal care.


Care home death in fall from hoist

In August 2010 May Ward, aged 100, was being moved by two carers at the Meppershall Care Home in Bedfordshire. She fell from a hoist and suffered multiple fatal injuries. The two carers had been employed for less than a year. The hoist used to move Mrs Ward had a complex operating procedure and the carers had not been trained in how to use it safely. The hoist was not recommended by the local authority as being suitable for Mrs Ward’s condition. She was not securely positioned and when she moved forwards she fell out.

There was a history of serious safety breaches at the Home. The HSE had served five improvement notices between October and December 2010 related to resident handling, risk assessment and a lack of competent health and safety advice.Another resident had suffered leg fractures after falling when being moved from a wheelchair to an armchair in September 2009.

Mohammed Zarook, the director of the company which owns the Home, had no knowledge or experience of running care homes. He proceeded to take vulnerable residents into his three care homes. There was no evidence that he had taken steps to fulfil his health and safety obligations through the provision of training and the management of risks most commonly associated with the care industry, including resident handling.

The Care Quality Commission had inspected the Home and had given it poor ratings. The Home was closed in July 2013.


Care scalding death

In June 2013 Joseph Hobbin, who suffered from cerebral palsy and epilepsy, was assisted into a bath in his home by a care worker employed by Ark Housing Association Ltd. As his legs were lowered into the bath he suffered an epileptic fit. His legs remained in the water and he sustained extensive scalding to his feet and lower legs. He died in hospital.

Mr Hobbin needed support in all aspects of day to day living. The local authority contracted Ark to provide his care.Ark had not provided care workers with training or instruction in relation to bath and shower temperature. The company was not aware of guidance in relation to safe bathing. It did not provide thermometers to staff and did not carry out adequate risk assessments in relation to the bathing of service users, including the deceased.


Fatal legionella exposure

In September 2012 Lewis Payne, aged 95, went to a care facility operated by Reading Borough Council. He had been in hospital and went to the care facility for intermediate care before returning to his home. He complained of tightness of the chest, shortness of breath, difficulty in breathing and nausea. He was readmitted to hospital and treated for Legionella’s disease. He died from legionella-related pneumonia.

Control and management arrangements at the centre were not sufficiently robust. Legionella training for key personnel were below required standards. There were inadequate temperature checks. Some of the checks of thermostatic mixer valves were done incorrectly.Showers were not descaled and disinfected quarterly as required. Flushing of little used outlets was reliant on one member of staff and there was no procedure for this to be done in the absence of that staff member. The failings were systemic and continued over a period of time. There was a history of legionella problems at the centre.Monitoring, checking and flushing tasks were the responsibility of the centre’s handyman. He was inadequately trained and supervised. There was no system in place to cover for him when he was away so that the requisite checks were not done.


Death of dementia patient from hoist

In April 2008 an 87-year old dementia sufferer was being cared for by the Kent and Medway NHS Social Care Partnership Trust at a Unit in Sittingbourne. As he was being bathed he slipped from a hoist and fell, suffering fatal injuries. The HSE investigation found that there was poor communication between the nursing staff and the agency care workers. The care plan was unclear and was not shared with agency carers. There had been no consideration of the risk of using a bathroom in another ward which precluded active supervision of the agency workers.
Care centre death from choking

In September 2012 Michael Breeze attended Shropshire Council’s run day services care centre, Hartley’s Day Centre, in Shrewsbury.The Centre caters for adults with learning disabilities. Mr Breeze was taken there for the day with a packed lunch provided by the carers at the residential home where he lived. At midday Mr Breeze started to eat his lunch. He started to choke and collapsed. He went into respiratory arrest and did not recover. He had a history of choking incidents. Appropriate safeguards were not put in place at the Centre despite these warnings.


Care home death from fire door

In November 2010 Irene Sharples, a 92-year old resident at Alexian Brothers Care Centre, was killed when a heavy fire door fell on her during renovation work.Healthcare Management Trust, the company which ran the home, engaged Rothwell Robinson Ltd to  carry out renovation work. Mrs Sharples, who suffered from dementia, wandered into a room where building work was being carried out. A fire door fell on her and caused fatal injuries. Both companies had failed to make sure that the room was locked when it was unoccupied. The fire door had been removed during the building work and leant against wardrobes. Other hazards in the room included loose skirting boards, exposed wiring, broken glass and rusty nails.


Death from asphyxiation in care home

In April 2010 Mrs Elsie Beals, aged 93, a resident of the Aden Court Care Home in Huddersfield, run by New Century Care Ltd, died from asphyxiation after being trapped in the gap between her mattress and incorrectly fitted bed safety rails. Mrs Beal had been a resident for two years. She had been helped to bed on the evening before her death by two care assistants. She was checked before midnight and was due another check two hours later. When the care assistants entered her room, they found her dead, trapped in the gap between her mattress and the bed safety rail. The company had failed to train staff at the care home to fit bed safety rails properly. Staff had not been trained to carry out regular in use checks to make sure that bed rails remained properly adjusted, nor to carry out risk assessments for their use.

Bed safety rails are used extensively in the health and social care sectors to protect vulnerable people from falling out of bed. The risks of their use are well documented, actively published and widely recognised in the health care industry.


In May 2016 Angus John MacLennan, who had learning difficulties and received 24 hour support from Western Isles Council, suffered serious burn injuries while bathing. The Council had failed to adequately manage the risk of scalding despite having been made aware of the risk through their own risk assessment. Employees had received no training in managing the risks of scalding, including how to run the bath or check the temperature. They had not been provided with thermometers.

Death from scalding

In 2011 an 89 year old woman was a resident of the Old Wall Cottage Nursing Home, operated by European Healthcare Group plc. She was receiving personal care from two employees when she died from scalding injuries. Bathroom taps were not adjusted to limit the safe temperature of the water. The company had policies and procedures in place, but they were deficient. The company had not effectively communicated information and instruction to staff, so that control measures could be properly implemented. An HSE inspector commented that all healthcare premises have a legal duty to control the risks of scalding injuries.

Hoist death

In November 2013 an 89-year old resident at the company’s care home in Sudbury, Suffolk, was moved by two care workers, using a hoist, from her bed to a chair. She slipped through the hoist sling onto the floor. She suffered a fractured femur and ribs. She died two weeks later. The company did not have adequate health and safety arrangements in place to ensure that users could be safely hoisted. There was no manual handling policy. Individual risk assessments were inadequate because they failed to provide specific information about the equipment to be used. This resulted in some residents being hoisted with the wrong type or size of sling. Nurses and care workers had not been given suitable training and several slings were found to be unsafe to use. They had not been inspected or examined for six months. Disposable slings were being washed and reused.

The Little Book of Horrors Part 2: bakers and butchers


Industrial bakery explosion death

David Cole, a baker, repeatedly attempted to light an industrial bakery oven. He was not aware that gas was building up to a critical flashpoint in the baking chamber. The gas exploded and blew the oven door from its hinges. Cole was struck and suffered fatal injuries. Andrew Jones Pies’ procedures for operating the oven was inadequate and informal. Bakery workers were not given sufficient instruction in its use or the potential hazards arising and precautions necessary to operate it safely. The company had failed to appreciate that direct-fired ovens could potentially fill with a flammable mix of gas and air if repeated unsuccessful attempts were made to fire them up. An explosion relief panel on the back of the oven, which should have safely vented excess pressure, had been rigidly fixed in place.




In July 2011 an employee of Rare Butchers of Distinction Ltd at its premises in Lewisham suffered a deep cut to his forearm while deboning a lamb shoulder. He was off work for more than three months and underwent physiotherapy to restore strength in his hand and thumb. The employee, who wishes to remain anonymous, was wearing a wrist-length chainmail glove. He should have been wearing a chainmail glove as far as his elbow. The company failed to report the incident within the ten-day limit required by RIDDOR. It took 29 days for it to notify the HSE.

Rollercoaster disaster: nine people hospitalised

Crown Office and Procurator Fiscal Service v M&D Leisure Ltd (2019) Hamilton Sheriff Court, March 8

Statutory reference: regulation 5 of the Provision and Use of Work Equipment Regulations 1998 (PUWER)

M&D Leisure Ltd, a theme park operating company, has been fined following an incident in which nine people were injured.

The facts

  • In June 2016 a train on the Tsunami rollercoaster at a Theme Park in Motherwell was carrying nine passengers.
  • It derailed as it was descending through a curve at a height of five metres. It crashed to the ground in an area containing mini-self drive cars and bicycles. All the passengers were injured and hospitalised.
  • The rollercoaster was not maintained in an efficient state or efficient working order.
  • It was not in good repair and weld repairs carried out on its axles were inadequate and unsound.

The decision

The company was fined £65,000 for a breach of PUWER.

An HSE inspector commented after the case that it was imperative that all controllers of fairground rides had thorough maintenance procedures in place to ensure that the public were safe when they were enjoying the thrills at a fair or theme park.

Long-term exposure to hazardous chemicals: employer fined £224,000

Health and Safety Executive v Fine Organics Ltd (2019) Teesside magistrates’ court, March 4

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

Fine Organics Ltd, a chemical manufacturing company, has been fined following the exposure of workers to chemicals.

The facts

  • Between October 2013 and December 2016 employees working with chemicals at the company’s Teesside plant were regularly exposed to chemicals harmful to health, which caused long-term damage to their skin.
  • Workers suffered rashes and in some cases were unable to continue working at the site.
  • The company had multiple failings in its handling of hazardous substances.
  • It had failed to prevent the release of hazardous substances, failed to prevent spread of contamination, failed to properly decontaminate and failed to have an effective system of health surveillance in place.

The decision

The company was fined £224,000 plus £17,000 costs under s.2 of HSWA.

Worker’s hand caught in machine: serious injuries: suspended sentence for employer

Health and Safety Executive v Edward Flitton t/a Hever Ironworks (2019) Norwich Crown Court, March 5

Statutory reference: s.2 of the Health and Safety at Work, etc., Act 1974 (HSWA); regulation 4 of the Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995 (RIDDOR) and regulation 1 of the Employers’ Liability (Compulsory Insurance) Regulations 1998 (ELCIR).

Edward Flitton, trading as Hever Ironworks, a foundry, has been sentenced following an incident in which a worker suffered serious hand injuries.

The facts

  • In February 2017 an employee of Flitton was working at an industrial estate in Stalham. She was wearing heavy duty gloves in accordance with company policy.
  • Her hand came into contact with a moving drill bit. It was entangled with the machinery. This resulted in severe tendon injuries and the partial de-gloving and severing of her left thumb.
  • Flitton had no safe system of work in place for workers using the machines, nor employers’ compulsory insurance in place.
  • The incident was not reported to the HSE by the employer but was reported by a third party.

The decision

Flitton was sentenced to a community order of 120 hours of unpaid work and a fine of £250 for breaches of s.2 of HSWA, regulation 4 of RIDDOR and regulation 1 of ELCIR.

Worker crushed to death by bus: £50,000 fine and suspended sentence

Health and Safety Executive v AD Hurst & Son Commercial Ltd and Alan Hurst (2019) Cambridge Crown Court, February 12

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

A commercial vehicle repair company and its managing director have been sentenced after a worker was fatally crushed by a bus.

The facts

  • In July 2017 an employee of the company was working in a vehicle inspection pit underneath a bus at the company’s site.
  • The rear of the bus had been raised and was supported by two bottle jacks. The bus fell from the jacks onto the worker, causing fatal injuries.
  • The company had failed to plan and organise the lifting of the bus in a way which ensured workers’ safety. The bottle jacks had been inadequate. The bus should have been supported so that it did not fall, using axle stands or other appropriate equipment.

The decision

  • The company was fined £50,000 plus £22,000 costs under s.2 of HSWA.
  • Hurst, the director, was sentenced to six months imprisonment, suspended for 18 months, under s.2 of HSWA.

Asbestos exposure: company in administration fined £1

Health and Safety Executive v Godfrey-Syrett Ltd (2019) North Tyneside magistrates’ court, February 21

Statutory reference s.2 of the Health and Safety at Work, etc., Act 1974 (HSWA) and regulation 4 of the Control of Asbestos Regulations 2012

Godfrey-Syrett Ltd, a manufacturing company, has been fined for failing to prevent exposure to asbestos.

The facts

  • In 2017 an employee of the company raised a concern about asbestos to the Health and Safety Executive.
  • Following an asbestos survey in 2003 which identified the presence of asbestos-containing materials, the company failed to introduce an adequate management plan or carry out remedial work to prevent potential exposure to asbestos fibres.
  • The company had failed to ensure that maintenance workers were made aware of the location of asbestos to ensure that it was not disturbed.

The decision

The company was fined £1 under s.2 of HSWA and regulation 4 of CAR. The fine was reduced from £800,000 because the company was in administration.

Traumatic workplace brain injury: £60,000 fine

Health and Safety Executive v H&M Distribution Ltd (2019) Cheltenham magistrates’ court, February 27

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

H&M Distribution Ltd, a distribution company, has been fined following an incident in which a worker suffered life-changing injuries.

The facts

  • In May 2017 an agency worker started work at the company’s Gloucester depot. He was engaged as a multi-drop delivery driver.
  • Following a short induction process the worker was delivering 12 beer kegs. He used a pallet truck to manoeuvre the kegs onto his lorry. He fell backwards from the raised tail lift of the lorry and several beer kegs fell onto him. He suffered a traumatic brain injury.
  • The worker had no experience of using the type of pallet truck or tail lift involved in the incident.
  • He had not been given any practical training in the safe us of the machinery, nor was he made aware of safe working practices on the way in which the pallet truck should be used.
  • The company had failed in its duty to carry out checks on the worker’s competence and previous experience.

The decision

The company was fined £60,000 plus £7200 costs under s.3 of HSWA.

An HSE inspector commented after the case that employers who used agency workers or contractors had a responsibility to establish their competence and experience and then to provide the appropriate level of training to ensure that the work was safely done.

Health and Safety Executive v Landor Cartons Ltd (2019) Birmingham magistrates’ court, December 20

Statutory reference: s.3 of the Health and Safety at Work, etc., Act 1974 (HSWA) and regulations 4 and 6 of the Work at Height Regulations 2005 (WAHR).

Landor Cartons Ltd, a carton manufacturing company, has been fined after a worker suffered fatal injuries in a fall.

The facts

  • In October 2017 a contractor working for the company at its site in Birmingham fell six metres to the site floor through a broken skylight. He suffered fatal head injuries.
  • The company had failed to assess the risks of working at height and had failed to implement a safe system of work, giving consideration to the hierarchy of control set out in the Work at Height Regulations.

The decision

Landor Cartons Ltd was fined £200,000 plus £12,000 costs under s.3 of HSWA and regulations 4 and 6 of WAHR.

An HSE inspector commented after the case that falls from height remained one of the most common causes of work-related fatalities. The risks associated with working at height remained well-known. Duty holders have a duty to protect contractors as well as employees.

Balfour Beatty fined £600,000 for workplace death

Crown Office and Procurator Fiscal Service v Balfour Beatty Civil Engineering Ltd (2019) Aberdeen Sheriff Court, February 25

Statutory reference: regulation 13 of the Construction (Design and Management) Regulations 2015 (CDM)

Balfour Beatty, a civil engineering contractor, has been fined following an incident in which a worker was killed.

The facts

  • An employee of the company was working at the construction site of the Third Don Crossing in Aberdeen.
  • He was struck by a wheeled excavator which was slewing after being refuelled. He suffered fatal injuries.
  • The refuelling of plant and equipment was classified as a high risk activity by the principal contractor. It had created a task briefing document which detailed a safe system of work and had risk assessed the work.
  • Although these procedures had existed in documentary format, they had not been fully implemented at the site.

The decision

The company was fined £600,000 under regulation 13 of CDM.

An HSE inspector is reported to have commented after the case that this had been a tragic and wholly avoidable incident. It had been caused by the failure of the company to implement safe systems of work and to ensure that health and safety documentation was communicated and control measures followed.