HSE Reminds Health And Social Care Organisations To Conduct Risk Assessments After A 90-yr Old Lady Dies, UK

Main Category: Seniors / Aging
Also Included In: Primary Care / General Practice
Article Date: 03 Dec 2008 - 1:00 PDT

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The Health and Safety Executive (HSE) is warning health and social care employers to ensure that risk assessments are carried out to determine the suitability of equipment used in everyday tasks.

The warning follows an incident that occurred on 25th March 2006 in the Elderly Directorate of Moseley Hall Hospital. Two auxiliary nurses were transferring 90-yr old Alice Belle from a commode to a bed, using a large sling and a battery-operated lifting hoist, when she fell from the sling to the floor and died at the scene.

HSE's investigation found that neither the hoist nor sling was defective but that the patient had slipped from the sling as it was too large. A coroner's verdict, in September 2007, was recorded as 'accidental death to which neglect contributed'.

South Birmingham Primary Care Trust was fined a total of £20,000 and ordered to pay costs of £17,500 at Birmingham Crown Court, on 1st December, 2008, after pleading guilty to breaching section 3(1) of the Health and Safety at Work etc Act 1974.

HSE investigating inspector Amanda James said:

"Alice Belle was a frail and vulnerable 90-yr old for whom the large sling, used at the time of the accident, was unsuitable. The moving and handling risk assessment, in place at the time, did not specify which sling should be used for the patient. A suitable risk assessment, carried out by competent staff, would have identified and recorded the appropriate type and size of sling and this should then have been communicated to all staff involved in moving and handling the patient.

"South Birmingham Primary Care Trust failed in its duty by exposing the patient to grave risk. It is essential to ensure that all equipment, including hoists and slings, is appropriate for the individual being moved or handled. It is also vital that professional carers and nursing staff receive adequate information, instruction and training in the correct selection and safe use of that equipment."

In a three-year period, from April 2004 to April 2007, HSE and local authorities received reports of approximately 92 incidents involving falls to patients or service-users, in the health and social care sector, where a hoist or sling was involved.

Judge Bill Davis QC, in summing-up, said: "Those who are most vulnerable need the most careful care and by pleading guilty the PCT accepted that, in this case, they didn't give proper care."

Notes

Section 3(1) of the Health and Safety at Work etc Act 1974 states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety".

In this instance, patients were 'non-employees' who were put at risk by South Birmingham PCT's failure to have a safe system of work in relation to:

- Selecting the correct size and type of sling to be used to lift patients; and
- Identifying the correct type and size of sling to be used for each task for patients in their records and effectively communicating the same to its employees.

Further information on managing risks in the healthcare sector can be found at http://www.hse.gov.uk/healthservices/index.htm

Health and Safety Executive