Apology after Hartlepool care home provider fined £24,000 following death of elderly resident on Christmas Day

The Hospital of God at Greatham has been fined £24,000 after being prosecuted by the Care Quality Commission over the incident at Gretton Court in Hartlepool on Christmas Day 2016.

The resident was found deceased in her bed and trapped between the bed and bed rails early on the morning. Infrared sensors had failed to activate.

A post mortem found the resident did not die as a result of the incident but had suffered a heart attack due to severe coronary artery disease.

But North Tyneside Magistrates Court heard that the Hospital of God had failed to provide safe care and treatment and exposed the resident concerned, and other people in the home, to a significant risk of avoidable harm.

Prosecuting counsel Ryan Donoghue, acting for CQC, said the failures were due to the provider not ensuring staff were competent in their roles and supported by relevant safety policies.

There were additional failures in correctly using and maintaining the PIR sensor system and the safe use and maintenance of bed rails; the combination of which led people to being exposed to significant risk of harm.

Investigations conducted by the CQC after the resident’s death confirmed that the bed rails had been previously broken between October and November, and the provider had repaired them.

But evidence showed that the rails were again broken during December 2016 but went unnoticed and therefore remained unrepaired for a number of weeks.

On December 30, 2016,a thorough CQC inspection found that health and safety checks were not always completed and the management of risks at the home was poor.

Care plans were also not being updated and the provider was not ensuring improvements were identified or addressed.

The service was rated Requires Improvement overall and two requirement notices were issued requiring the Hospital of God to say how it intended to make improvements to the service.

The Hospital of God says it has learned from the incident and put measures in place to make sure it cannot happen again.

Gretton Court's CQC rating has since improved to Good overall.

The Hospital of God pleaded guilty at South Tyneside Magistrates’ Court, on March 13, to two offences: failing to provide safe care and treatment resulting a resident being exposed to a serious risk of avoidable harm, and a failure to provide safe care and treatment to the residents of Gretton Court from being exposed to a significant risk of avoidable harm.

It was also ordered to pay £14,000 towards the cost of the prosecution, and a £170 victim surcharge.

Sue Howard, Deputy Chief Inspector of Adult Social Care at the CQC, said: “Everyone who depends on services is entitled to safe high-quality care and to be protected from harm. We found this provider had failed to ensure risks to people had been fully assessed or actions taken to prevent people from being exposed to avoidable harm.

“The combination of a lack of the home assessing risk and its poor governance meant that it failed to identify where improvements were needed and ultimately resulted in CQC taking this action.

“We would like to offer our sincere condolences to everyone concerned with the death of the resident.

“Where we find poor care, we will always consider using our enforcement powers to hold providers to account and to ensure the safety of the people using services.”

In a statement the Hospital of God said: "The charity agrees that it had not provided safe care and treatment to one of its residents resulting in them being exposed to a risk of significant harm. Further to this, this deficiency in its systems, reporting and training arrangements also put other residents at risk.

"The Hospital of God fully acknowledges that in this instance our systems and process were not sufficient, which is far from good enough.

"We have learnt from this and introduced changes to procedures to ensure, this does not repeat itself. It is so far from what we want to achieve and what we strive for.

"We would never want a situation where people are put at risk of harm and we apologise unreservedly. We are fully committed to provide the very best services for people.

"We have learnt from this experience and the incident which happened in December 2016, and have put in place a number of measures to ensure this cannot happen again.

"This is reflected in our “good” rating for the home from the Care and Quality Commission and with their support, the support of our residents, their families and carers, our staff and other partners we will continue striving towards achieving excellence and providing the very best, safest care we can."