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Care Home Prosecution – Deceased resident found trapped between bed and bed rails

The CQC brought a prosecution following the death of an 83 year old woman who was found trapped between her bed and bed rails at Gretton Court Care in December 2016. A post-mortem confirmed that death was caused by a heart attack due to severe coronary disease.

Due to the resident being assessed as at risk from falling from bed when resting, it was determined that bed rails and passive infra-red sensors, which alarm on detection of movement, should be implemented. The need for bed rails was later reassessed, however staff responsible for completing assessments and for safe use of bed rails had not received appropriate training. Bed rails remained in use for this resident.

A comprehensive inspection conducted by the CQC shortly after the death found health and safety checks were not always completed and the management of risk at the home was poor. Care plans were not updated as required and governance processes were not robust enough to identify and address issues as appropriate. Investigations after the resident’s death confirmed that the bed rails had been broken and despite being repaired, had broken again. However, this time they had gone unnoticed and therefore remained unrepaired for a number of weeks. It was also noted that the sensors which had been implemented for the safety of the resident had not activated at the relevant time. The CQC rated the service as ‘Requires Improvement’ and issued requirement notices, requesting a report from the provider as regards how remedial works would be implemented and monitored.

Prosecuting Counsel for the CQC explained that the Provider had failed to ensure that staff were competent in their roles and the CQC also identified an absence of relevant safety policies. Additional concerns related to the maintenance of the sensor system and use of bed rails more generally.

The Provider, Hospital of God at Greatham, pleaded guilty to two offences concerning breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; the duty to ensure care and treatment is provided to service users in a safe way. This includes doing all that is reasonably practicable to mitigate risks to the health and safety of service users. As Providers will be aware, it is a criminal offence if the failure results in avoidable harm to a service user or exposes a service user to a significant risk of exposure to avoidable harm. The provider was fined £24,000 for failing in its duty, £14,000 towards the cost of the prosecution and a £170 victim surcharge.

Sue Howard, Deputy Chief Inspector of Adult Social Care, has since commented, “where we find poor care, we will always consider using enforcement powers to hold providers to account and to ensure the safety of the people using the service”.

For further examples of CQC prosecutions you may wish to review last month’s update.


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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