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Issue 1: Falls from improper use of equipment
Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Falls from equipment can result in serious or fatal injuries.
When using equipment, such as a shower chair, to support people with personal needs, it is important to use safety belts to keep people safe and secure.
Prosecution by CQC
In June 2016, CQC successfully prosecuted a nursing home provider.
The provider failed to:
- make sure that staff understood how to safely fit straps on a shower commode chair
- carry out effective equipment audits
This resulted in an incident when two care workers supported a 62-year-old man to take a shower using a shower commode chair. The shower chair fell forwards while he was loosely strapped in. The man, who had Down’s syndrome, epilepsy, dementia and a severe learning disability, fell and broke his neck.
Staff tried to resuscitate him, but he died in hospital.
The provider pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to a person using the service. The court ordered the provider to pay:
- a £190,000 fine
- £16,000 prosecution costs
- a £120 victim surcharge
The provider has taken steps to improve
Following the incident, CQC inspected the service and found it to be in breach of regulations, including in relation to safe care and treatment. We received an action plan from the provider, and at a follow-up inspection found that all actions had been completed and improvements made:
- all risk assessments were detailed and helped reduce risks to the safety of people living at the home
- staff were supervised, appraised, mentored and trained to ensure they had the skills to provide a high-quality service
- monthly audits were now carried out by the area manager and actions monitored to make sure they are completed
The service is now rated good overall.
What can you do to avoid this happening?
Unfortunately, this sort of incident is not uncommon, but you can do something to reduce the risk.
The Medicines and Healthcare Products Regulatory Agency (MHRA) issued two safety alerts in 2008 and 2015 about the use of posture and safety belts fitted to supportive seating, wheelchairs, hoists and bathroom equipment.
The 2015 alert stressed the importance of making sure that:
- the belts were the right type for that person and adjusted correctly
- care staff receive training on how to check, adjust, clean and maintain each device safely
- Last updated:
- 22 June 2018