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A care provider has been fined after being found guilty of health and safety breaches after a vulnerable adult with severe learning difficulties drowned in a bath.

Glasgow Sherriff’s Court heard that on 10 June 2016 one of the residents, a vulnerable adult with severe learning difficulties, drowned in a bath within her flat in the early hours of the morning.

The company had supplied a baby monitor to alert support workers that she was out of bed but a HSE investigation found that it was neither suitable nor sufficient as she was so light on her feet. The two support workers, one of which was on her first shift and who also were supporting four different service users in four different flats, failed to hear that she was out of bed.
Sometime during the early hours of the morning of 10 June 2016, she was able to run a bath in which she subsequently drowned. The water to the flat should also have been isolated but neither carer knew to do so.

HSE’s investigation concluded that there were severe staff shortages at the time of her death which resulted in two carers who were not familiar with her being put in charge of her care over-night. The company had no specific induction procedures and relied on staff finding time to read the care plans after their shift had commenced. There were no clear shift plans to alert the support workers to the critical needs of the four people they were supporting and no clear instructions on how checks should be made. Staff had raised concerns on a number of occasions after finding her out of bed, but the company had failed to put more appropriate measures such a door sensors or pressure mats in place.

The company pleaded not guilty to charges under Section 3 of the Health and Safety at Work (etc) Act 1974 but were found guilty following a two-week trial. The organisation was fined £450,000.

Speaking after the hearing, HSE inspector Kathryn Wilson, said: “This was a desperately tragic case which has left the family devastated. The baby monitor was a wholly inappropriate method of alerting staff that a resident was out of bed, being designed to alert a parent that a baby is crying or choking. “She should have been safe at the premises but a failure by the company to identify and put in place simple and reasonably practicable safety measures resulted in two support workers being given insufficient information to protect this vulnerable lady in their care.”

Source – HSE

HSCS Scotland Promoting a Healthier Workplace Through Safety

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