Healthcare - July 2010

Negligent care could lead to a charge of Corporate Manslaughter

An NHS Foundation Trust was fined £50,000 this month and ordered to pay £40,000 in costs following the tragic death through asphyxiation of a severely disabled young man (KF) in 2006 after his head became trapped between the bottom rail surrounding his bed and the edge of the bed itself.

Twenty year old KF had the body of a twelve year old boy.  He was blind, deaf, quadriplegic and had cerebral palsy.  The Court heard that during the night before KF died, he was found on several occasions to have been lying diagonally in his bed and with his head wedged between the rails.  He was repositioned twice by nurses but later, despite concerns raised by a passing cleaner he became trapped, but no action was taken. It transpired that there had been a similar incident during an earlier stay at the hospital when KF had suffered bruising, swelling and a bleeding mouth after he forced his head part way through the rails.

Department for Health guidelines published in 2001 highlighted the fact that people with cerebral palsy are known to be particularly at risk of entrapment.  The hospital staff had no knowledge of the previous incidents and KF was placed in a single room without one-to-one care and monitored at irregular intervals.  Disregarding KF's size, he was placed in a bed with adult spacing bed rails and no bumpers.  Had the correct bed been used it would not have been physically possible for KF to place his head through any gap. 

The Trust was investigated by the Health and Safety Executive (HSE) and a prosecution was brought under s.3(1) of the Health and Safety at Work etc Act 1974.

The HSE investigation found that the Trust had no systems in place on each ward for assessing the risk to patients from bed rails and that the Trust's practice for obtaining, recording and disseminating information about KF's needs was poor.  Staff did not formally share knowledge of individual patients and concerns raised by staff were not recorded and acted upon.  There was no system in place to alert staff to a patient’s particular needs or habits.  Instead staff were relied upon to remember the patient from previous visits or to retrieve records to read through past medical notes.

This systematic failure led directly to this tragic death and whilst the prosecution was brought under the Health and Safety at Work etc Act 1974, if brought now given the systemic failings there would have been a distinct possibility that the prosecution could have been brought under the Corporate Manslaughter and Corporate Homicide Act 2007.

This comes as a timely and salutary warning to managers to review, update and implement appropriate procedures to ensure that such tragic incidents do not recur and that Trusts comply with health and safety legislation.

Leigh Carter, Solicitor
Weightmans LLP