12 September 2017
Introduction
The States Employment Board (SEB), the legal entity that employs staff working for the Health and Social Services Department (HSSD), was fined £50,000 by the Royal Court on 18 August 2017, after pleading guilty to an offence under the Health and Safety at Work (Jersey) Law 1989 (HSW Law).
Costs of £10,000 were also imposed.
Background
The prosecution arose from an incident on 02 March 2016 involving an 83 year old patient, who was suffering from dementia and being cared for on Oak Ward, Rosewood House, St Saviour. The patient fell from a bath hoist hitting her head on the floor and subsequently died on 06 March 2016 as a result of the injuries sustained.
The prosecution
SEB pleaded guilty to a charge under Article 5(1) of the HSW Law, which requires employers to ensure, so far as is reasonably practicable, that persons not in their employment, including patients, are not exposed to risks to their health and safety by the manner in which they carry out their undertaking.
During the investigation a series of failings were identified. These included:
- a seat belt supplied by the hoist manufacturer was not fitted to the bath hoist seat, despite the need for this being the subject of several ‘Medical Device Alerts’ issued by the UK Medicines and Healthcare products Regulatory Agency following accidents involving patients falling from the same type of bath hoist
- although a seat belt was available on Oak Ward, employees had an inconsistent understanding regarding its use, and how to fit it, when using the hoist
- employees were not trained on the correct use of all aspects of the equipment they would be using on the ward (‘familiarisation’ training) and suitable refresher training had not been provided to ensure that experienced employees’ knowledge did not deteriorate over time
- the use of the bath hoist was not adequately monitored and audited to identify evidence of incorrect practice
- no robust measures were in place to review patient’s individual care plans, which provide direction for individualised care and support based on the patient’s needs, including a review of assessments within the appropriate time period
- no robust measures were in place to communicate key aspects of care plans, including individual assessments, to all relevant employees and to ensure that key information was fed-back to the key members of staff responsible for reviewing and updating the care plans
Comments
The risk of a fall associated with the use of bath hoists is well documented. In its conclusions, the Court stated that this case represented a ‘wholly avoidable and unnecessary loss of life’, resulting from inadequate training, poor procedures and a failure at all levels of management over a long period of time. This was acknowledged by the SEB, who expressed its unreserved apology to the family and confirmed that significant changes and improvements had since been put in place to help ensure a similar incident does not occur.
gov.je