A healthcare company has been fined £50,000 over the death of a nursing home resident in Lisburn who suffered major injuries in a fall.
Mary ‘Pat’ Thompson had been a patient at Rose Lodge nursing home when she fell off the edge of a bed while unattended.
An investigation by the Health and Safety Executive for Northern Ireland (HSENI) found that she had fallen forwards on to the floor, suffering multiple injuries before her death in the following days in hospital.
The Belfast-based company Harmony CCS Limited received the fine after pleading guilty to a single health and safety breach.
Speaking after a court hearing, HSENI Inspector Kiara Blackburn said: “Care plans must identify the specific care needs of each resident and should be followed by all care staff. Staff should not be reliant on informal assessments to determine a resident’s needs.
“Any changes to a resident’s needs should be adequately risk assessed, documented and the information communicated to all care staff.”
The investigation revealed that Mrs Thompson’s care plan indicated that she needed two carers for safe moving, handling and transferring activities.
Despite this, this was not clearly spelled out within the care plans.
At the time of her fall, a junior member of staff was told by a senior colleague to provide personal care for Mrs Thompson on their own.
As a result, she was moved by one carer and left unattended at the edge of the bed when she fell.
The investigation also found out there was no formal system in place to identify if the personal care had been carried out by one or two carers.
Instead, staff used an informal daily assessment of Mrs Thompson’s presentation to decide on her needs.
The HSENI said his practice “highlighted the failure of the company to ensure that adequate systems were in place to ensure the safety of residents, and to ensure that all staff were adequately trained and supervised to carry out their work safely.”
