OWNERS of a Sheffield care home have been fined £20,000 after a frail woman died when her head became trapped by a rail as she fell out of bed.
Daphne Watkins, aged 83, had fallen out of bed 16 times in 27 months at Darwin House in Crosspool, Sheffield, and on the last occasion she got wedged between the mattress and a grab rail.
The retired secretary, who had Parkinson’s Disease, had previously trapped her head behind the bed rail three times, including one incident just a month before her death in August 2009, but no action was taken by management.
A jury at an inquest in 2010 into Mrs Watkins’ death returned a narrative verdict, but said equipment in Mrs Watkins’ room was inappropriate, and there was no effective policy to pick up on incidents.
Sheffield Council prosecuted Darwin House Ltd, owners of the home, under the Health and Safety at Work Act. The company pleaded guilty to breaches.
Judge Rosalind Coe QC ordered the company to pay a £20,000 fine and £7,000 costs.
Sheffield Council told the court an investigation by its own health and safety team revealed the home had failed to carry out a suitable risk assessment on the use of the grab rail for Mrs Watkins.
Officers said an assessment should have identified the rail be removed.
The Department of Health had issued an alert about the dangers of grab rails three months before Mrs Watkins moved into the home.
But a director of Darwin House Ltd at the time told council officials they had no knowledge of the alert.
Mrs Watkins’ son Anthony had not been informed of the number of falls she had suffered, including those involving the rail, and was ‘shocked’ when he found out.
A snap inspection by the Care Quality Commission after Mrs Watkins’ death rated the home ‘poor’ and removed its two stars.
They were reinstated in February 2010 after a recovery plan.
A spokesman for the home said today: “Daphne Watkins was a much loved resident and her accident came as a great shock to all those concerned with her care.
“Since Darwin House was first set up almost 25 years ago, it has never had an incident of this nature.
“We are relieved that after three years this matter is at an end and our thoughts are very much with Mrs Watkins’ family.”