Failure in risk management leads to tragic consequences

Three tragic cases recently reported in the care sector highlight the importance of thorough and ongoing risk assessment processes with management oversight, that ensure all risks and controls are properly communicated to workers.

Not only did the three incidents result in tragic – and heartbreakingly avoidable – loss of life, the reputational and financial costs to the respective businesses were substantial. Besides this, the length of time from the dates of the incidents to the prosecutions will have placed both personal costs on family members, witnesses and managers and additional business costs throughout the prolonged investigation process.

Although these incidents occurred in the care sector, the lessons learned apply across all industries.

Case one

A care home business, run by one of the UKs leading private health care providers, was recently fined over £1 million following the death of a resident who died in a fire. The fire resulted from them smoking a cigarette at one of its care homes.

The cost breakdown awarded by Southwark Crown Court on 5 January 2021 was:

• £937,500 for fire safety failings
• £104,000 prosecution costs

The London Fire Brigade brought the prosecution against the operator of the Care Home under the Regulatory Reform (Fire Safety) Order after it was called to the blaze in March 2016.

The 69-year-old wheelchair user died in a fire whilst smoking un-supervised in a shelter in the garden of the premises. Investigations found that although a smoking risk assessment had been carried out for the resident it did not assess his use of emollient creams, which can be flammable if allowed to build up on skin, clothes or bedding.

It also became apparent from historic burn marks on clothing that this incident was not the first of its kind. Care home staff claimed they had been unaware of these previous incidents.

London Fire Brigade brought the case as there had been a failure to comply with fire safety duties which placed the specific resident and other residents at risk of death or serious injury in case of fire.

The Company pleaded guilty to contravening Article 11 (1) which relates to the management of fire safety measures.

Specifically, it accepted that it had failed to:

• Ensure staff understood the risks from the use of emollient creams
• Warn residents using paraffin-based products not to smoke, or require precautions to be taken such as the use of smock or apron
• Instruct staff not to leave a resident using paraffin-based products smoking unsupervised
• Carry out an individual smoking risk assessment of the residents as normal with the control measures in place.

The Brigade’s Assistant Commissioner for Fire Safety, said:

“This case is an absolutely tragic example of what the devastating consequences of failure to comply with fire safety regulations can be.

“If there can be anything constructive to come from this, we hope that it will be that anyone who has a legal responsibility for fire safety in a building, whether it’s a landlord, a property manager, care home provider or any other setting, take notes and makes sure they are complying with the law.”

Case two

A care home operator in Scotland was recently fined £640,000 following an incident when a resident choked to death on a jam doughnut.

The resident was given a piece of jam doughnut to eat on 7 August 2019. This was despite the resident requiring a ‘minced and moist/fork mashable’ diet due to a high risk of choking, who had previously suffered from a stroke and had been diagnosed with dementia. A jam doughnut is known to be unsuitable for someone on this diet and should not have been given to her. She died as a result of choking on the doughnut.

The investigation by the Health and Safety Executive found that staff who gave out snacks had not been properly trained and did not have awareness of food that was suitable for each diet. They regularly gave this resident unsuitable food for her diet in breach of their own risk assessment.

The operator of the care home pleaded guilty to breaching the Health and Safety at Work etc. Act 1974, Section 3(1) and Section 33(1)(a) and were fined £640,000.

After the hearing, HSE Inspector, Allison Aitken said: “Those in control of work have a responsibility to devise safe methods of working and to provide the necessary information, instruction and training to their workers in the safe system of working.

“If a suitable training had been in place prior to the incident, the sad death of a resident could have been avoided.”

Case three

In a particularly devastating case, a nursery was fined £800k after a baby choked to death on its premises.

On 9 July 2019, the eleven-month old boy was eating dinner at the nursery when he began to choke. The staff member on duty was using the bathroom at the time, and at first didn’t realise the boy was choking. On realising he wasn’t breathing, she and the other staff members attempted to dislodge the blockage and when paramedics arrived they were able to remove it. However unfortunately the boy died the following day.

On investigation, it was discovered that the nursery employees weren’t properly instructed on how to control the risk of chocking at mealtimes. There was also a number of occasions where the staff were involved in other tasks at mealtimes, meaning they weren’t supervising the children eating.

At Edinburgh Sheriff Court, the nursery admitted failings under Health and Safety at Work legislation and was fined £800,000. After this event, the company changed its health and safety policies and procedures.

Alistair Duncan, head of the health and safety investigation unit of the Crown Office and Procurator Fiscal Service said:

“This tragic death could have been prevented if staff had been given suitable instruction and supervision in relation to their duties to properly supervise children’s mealtimes.

“Childcare providers have an enormous responsibility to ensure the safety and wellbeing of the children in their care, but in this case, [the nursery] failed to live up to that responsibility.

“This should serve as a warning to others of the devastating consequences of such failures.”

Common lessons learned in these cases

Risk Assessments are all to often seen as a one-time paperwork exercise, when in fact a risk assessment is a living document that records ongoing changes in the task, activity or area covered by the risk assessment.

As we see in these tragic cases, the findings of the risk assessments need to be communicated to employees, workers and others involved in the activity. Furthermore, management must put in place procedures to provide workers with adequate information, training, instruction, and supervision to ensure all Hazards, Risk and Controls are known and implemented correctly.