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Care home briefing 104 – Care home company heavily fined after resident death

A Bupa care home company has been fined £100,000 after a 91-year-old resident died following a fall from a hoist during a manual handling operation.

The resident, Irene Evans, lived at Parklands Court Nursing Home in Bloxwich, Walsall, which is run by Bupa Care Homes (CFH Care) Ltd.

On 31st January 2007, two carers were moving Mrs Evans from a bed to a chair. They placed a sling underneath Mrs Evans, which was then attached to a hoist. Whilst the hoist was stationary, one carer turned away to pick up Mrs Evans’ slippers and as a result the resident fell forwards to the ground. She suffered a five-inch wound across her scalp and bruising to her head. She was taken to hospital but sadly died 10 days later.

A Health and Safety Executive (HSE) investigation into Mrs Evans’ death found that the sling loop fixings attached to the hoist were wrongly adjusted. In addition, a safety pommel was not used, which would have prevented Mrs Evans from falling.

The HSE prosecuted Bupa Care Homes (CFH Care) Ltd under section 3(1) of the Health and Safety at Work etc Act 1974 (“the Act”). The hearing took place at Wolverhampton Crown Court.

The Court heard evidence that Bupa Care Homes (CFH Care) Ltd had failed to:

  • Provide the staff at the home with any information, instruction or training in the use of the sling, the pommel or the sling loop fixings;
  • Record the sling loop fixings in the risk assessment and the care plan for Mrs Evans;
  • Provide a safe working procedure for the sling.

Bupa Care Homes (CFH Care) Ltd pleaded guilty to breaching section 3(1) of the Act and as a result was fined £100,000 and ordered to pay £50,000 in costs.

In mitigation, the Judge accepted that Bupa Care Homes (CFH Care) Ltd had cooperated with the HSE investigation, promptly admitted its guilt and subsequently implemented measures to avoid any repetition. The Judge also considered that the number of falls during hoist transfers at Bupa Care Homes (CFH Care) Ltd did not indicate that there was a wider problem within this particular care home or within Bupa as a whole.

Following the hearing, the HSE’s prosecuting inspector, Amy Kalay, said that “Mrs Evans'” death was a wholly preventable tragedy caused by unacceptable management failings on the part of Bupa…Working in a care home is a specialised job, which involves dealing with vulnerable people. Care homes must ensure that they have the correct training in place for all their employees.”

This case serves as a strong warning to all care home operators. Care home managers must ensure that residents’ manual handling requirements are properly assessed, and that carers are given clear information, instruction and training on how to use manual handling equipment.


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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