Care home owner fined thousands after 98-year-old's bed fall death

The owner of a care home has been ordered to pay £163,185.15 for care failings that led to the death of a 98-year-old man who fell from his bed.

The Care Quality Commission (CQC) has prosecuted Joseph Rowntree Housing Trust, the owner of Lamel Beeches care home, for failing to provide safe care and treatment at the setting after resident Alfred Colley died when he fell out of bed and broke his hip.

Refractured his hip in second fall

Leeds Magistrates Court was told the 98-year-old fractured his hip during a fall at the York-based care home in August 2015 but was discharged back to the setting following treatment in hospital. Less than four weeks later, Mr Colley fell out of bed and re-fractured his hip. He died later in hospital.

The court was told Mr Colley’s second fall could have been avoided, had Lamel Beeches followed correct procedures around bed rail safety.

CQC concerns about bed rails

A safety consultant had identified 14 beds that needed bed rail extensions to prevent the occupants falling but the provider did not authorise the work until after Mr Colley’s accident. There were also four other incidents in which Mr Colley had become trapped in the bed rail, or attempted to climb over it, prior to breaking his hip.

When CQC inspectors visited the care home, they found concerns around the use of bedrails used by every one of the 10 people they checked on, revealing action had not been taken to manage risks or keep people safe.

A spokesperson for the CQC said: “When we inspected Lamel Beeches last November, we identified concerns around the use of bedrails and the provider had not authorised work to improve bedrail safety until after Mr Colley's accident.”

’He deserved a better death’

In a victim impact statement, Michael Colley, Alfred's son said: “Although my father was very old and increasingly frail, I was still able to take him out for brief trips, and he maintained his former interests in golf, rugby and cricket as a spectator.

“He engaged enthusiastically with family matters, taking particular delight when new great grandchildren visited.

“Any bereavement is distressing, but these circumstances have made my father’s death particularly so. At the age of 98, death is not an improbable event. However, my father underwent unnecessary pain and distress. He deserved a better death.”

Mr Colley fell out of bed or ‘became trapped in the rails a number of times’

Debbie Westhead, CQC’s deputy chief inspector for adult social care said: “This was avoidable. We know that Mr Colley had fallen out of bed, or become trapped in the rails a number of times – but still too little was done to keep him safe.

“It is clear that the provider in this case had failed to keep safe the frail people in its care. They had not ensured that the bed rails were being safely used. Risk assessments were not suitable, staff had not been trained and they had not taken action to deal with the risks which had been identified.

“Taken together, the provider’s poor governance and leadership at the home led to unsafe care and treatment on the part of its employees.

"If we find that a care provider has put people in its care at risk of harm, we will always consider using those powers to the full to prosecute those who are responsible.”

The Joseph Rowntree Housing Trust pleaded guilty to two offences and was fined £100,000 for failing to provide safe care and treatment to Mr Colley and £50,000 for failing to provide safe care and treatment which exposed people to a significant risk of avoidable harm. They were also ordered to pay the prosecution costs of £13,000.15 and a £170.00 victim surcharge.

This is the fifth prosecution the CQC has brought against care providers since inheriting special enforcement powers from the Health and Safety Executive and local authorities in April 2015.

Trust 'deeply regret the missed opportunities'

Shaun Rafferty, strategic director of communities at the Joseph Rowntree Housing Trust said: “We fully accept the court’s judgment and deeply regret the missed opportunities in the lead up to Mr Colley’s sad death.

“We wrote to Mr Colley’s family immediately after the incident occurred and apologised fully. We are deeply sorry to Mr Colley’s family and offer our sincerest condolences to them.

“We have co-operated fully with the CQC’s investigation and worked closely with them to quickly make the necessary improvements. We fully recognise there have been issues in parts of our services. This is not acceptable and we are working hard to rectify them.

“We have a new leadership team in place and we are delivering an improvement plan so that residents experience the best possible service. Eight out of nine of our care settings have a ‘Good’ rating from the CQC, including Lamel Beeches, and we will continue to build on this progress.

“We want to reassure our residents and our families in all our care homes that they are safe and will continue to receive high quality care.”