A major care home group has been fined £1.6 million following the death of a resident from hypothermia after a health and safety prosecution brought by Harrogate Borough Council. The company pleaded guilty to a breach of the Health and Safety at Work Act 1974 at an earlier hearing.
Mrs B, aged 91, suffered from dementia. Her temperature was found to be 25.3C, nearly 10 degrees below the hypothermia threshold of 35C when attended to by the ambulance service after the alarm was raised by a member of staff who attended her room and found her in an unresponsive state. York Crown Court heard the resident had not been given any hot food or drink as she spent her last day asleep in her room. Investigations revealed that the radiators in her room were not properly maintained and staff had expressed previous concerns about that the oil fired heating system in the Home did not work properly. The only maintenance person on site was said to be a handyman without the relevant qualifications or experience, who only worked mornings.
Mrs B resided at the Home following a fall in July 2012. In October 2012, she suffered a further fall whilst resident at the Home and was taken to Harrogate District Hospital for treatment. Her discharge letter stressed that she should be kept warm. This was perceived as a "cautionary note" by Judge Paul Batty QC who described systematic and systemic failure at the Home where there was no amendment to the resident's care plan following this incident.
Currently the Home is rated as "good" by the Care Quality Commission ("CQC") under the new inspection regime. Following the death of Mrs Bin November 2012, a safeguarding alert was issued by the ambulance service that triggered a targeted CQC inspection under the old regime. This identified concerns and failings that most probably underpinned the conclusion by the sentencing judge that the failings went beyond this case. This analysis is reflected in the level of fine imposed under the new sentencing guidelines for health and safety offences that came into force on 1 February 2016. The new guidelines direct the courts to consider the sentencing of offending organisations by way of a step-by-step approach, looking at culpability, the seriousness of harm risked and the likelihood of harm; these are divided into a number of different levels to reflect the scale within each category. The guidelines require an assessment of turnover in order to establish a starting point for a fine that is intended to bring the message home to the directors and shareholders of offending organisations. Whilst the guidelines are still in their first year, there has been real consistency in relation to the level of fines that have been imposed which have been significant, providing even more of an incentive for businesses to ensure compliance in relation to their health and safety obligations.
This case was prosecuted by the local authority but it will be interesting in the future to see whether these cases such as this are prosecuted by the CQC given their sector awareness and regulatory powers. Since 1 April 2015 there has been a transfer of enforcement responsibility for health and safety incidents in the health and social care sector from the Health and Safety Executive and local authorities to CQC who bring these cases as a breach of the requirement to provide safe care and treatment. Clearly as a minimum, any investigations following adverse events such as this will feed into a company's risk rating and profiling..