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Care homes briefing 185 – Recent CQC prosecutions

In order to enable steps to be taken to seek to avoid repeated harm, the CQC’s website published a series of briefings to enable ‘Learning from safety incidents’. These cover:

  • Falls from improper use of equipment
  • Unsafe use of bedrails
  • Fire risk from use of emolument creams
  • Burns from hot water or surfaces
  • Safe management of medicines
  • Caring for people at risk of choking

Care providers will be familiar with these as areas of risk and will wish to have plans in place to address these.

Outcomes of prosecutions

The learning briefings also record the outcome of prosecutions in relation to several of these issues:

  • Improper use of equipment – An elderly resident with Down’s syndrome and dementia fell from a shower chair in which he was only loosely strapped, and subsequently died. The provider pleaded guilty to failing to provide safe care and treatment and was fined £190,000.
  • Bedrails – A 98 year old resident became trapped in a bedrail or attempted to climb over it on four occasions. A safety consultant had previously identified the need for bedrail extensions but use of these had not been implemented. The provider was prosecuted and received a £150,000 fine.
  • Hot surfaces – A 79 year old resident at high risk of falls had been risk assessed as requiring a sensor mat and hourly checks. In the absence of these, she was found to have a large burn from an uncovered radiator.  The provider was prosecuted and a fine of £20,000 was imposed.
  • Management of medicines – The provider failed to order a fresh prescription of anti-coagulation medication for a resident who died from a pulmonary thromboembolism and DVT. The provider was prosecuted and ordered to pay a fine of £50,000.
    The registered manager was also prosecuted and ordered to pay a fine of £665.
  • Choking – The CQC prosecuted a provider for failing to maintain accurate care records and pass on advice from the speech and language therapy team in relation to a resident with swallowing difficulties. He choked and died.  The provider was ordered to pay a fine of £82,429.

In our previous briefings, we have highlighted the increase in enforcement action by the CQC. Prosecution action often starts with a letter requesting a response to potential allegations or a request for an interview under caution.

Providers would clearly be well advised to ensure that they obtain early advice from specialist solicitors in such cases.


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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