Four Systems Defects Responsible for Hospital Patient Death of Cerebral Palsy Patient

Following the death of a disabled patient Basildon and Thurrock University Hospitals NHS Foundation Trust was fined £50,000 ($72,708) for failure to have patient risk assessment measures in place.

The boy’s death was a result of failure of staff to properly monitor and care for the severely disabled 20 year old during his hospital stay. The patient suffered other injuries during a previous stay at the hospital.

During the admission when he died, no assessment of his needs was carried out and staff had no knowledge of the previous incident. The man, disabled from cerebral palsy, was placed in a single room without one-to-one care and only monitored at irregular intervals.

HSE investigation found following four problems/defects:

1. The Trust had no systems in place on each ward for assessing the risk to patients from bed rails. People with cerebral palsy are known to be particularly at risk of entrapment and the issue was highlighted in Department for Health guidelines published in 2001.

2. The Trust's practice for obtaining, recording and disseminating information about the patient’s needs was poor. Staff did not formally share knowledge of individual patients.

3. There was no system in place to alert staff to his particular needs or habits, instead staff were relied upon to remember him from previous visits or to retrieve records to read through his past medical notes.

4. Although the man’s body was the size of a 12 year old boy, he was placed in a bed with adult spacing bed rails. Had the rails been suitable for his size it would not have been physically possible for him to get his head through any gap.

The NHS Foundation Trust was sentenced after it admitted failing to ensure the health and safety of patients in its care, breaching Section 3(1) of the Health and Safety at Work etc Act 1974. It was fined £50,000 ($72,708) and ordered to pay £40,000 ($58,166) in costs. (workersxzcompxzkit)

Sue Matthews, HSE Inspector, noted, "This was an entirely preventable incident that resulted in the death of a vulnerable and much-loved young man. Hospitals are subject to the same safety regulations as any other organization and HSE will ensure that those who breach health and safety requirements, or fail in their responsibilities, are held to account."

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.

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