Changes introduced in States residential home following patient's death

Sunday 20 August 2017

The Health and Social Services Department has introduced a series of changes in residential homes following the death of an elderly woman at Oak Ward in March 2016.

The States Employment Board who are responsible for HSSD staff was fined £50,000 in Royal Court on Friday.

The victim, 83-year-old Mary Cornish, had dementia and was a resident of Oak Ward at Rosewood House - a States-run residential home on the St Saviour's Hospital complex site.

On the morning of 2 March 2016, she suffered a fall whilst being bathed by two healthcare assistants. At some point during the process, Mrs Cornish went stiff and rigid and one of the staff tried to lower the seat down. As he was doing so, the left armrest was raised up meaning that the woman was only restrained by the left hand of the assistant. As he was located at the rear of the hoist, he was unable to prevent her from "diving" forwards and to her left. Mrs Cornish fell straight to the floor and struck her head. She suffered an extradural haematoma and died from her injuries on 6 March. 

The Health and Safety Inspectorate (HSI) conducted an investigation into the incident. They concluded that the States' Employment Board (SEB) had committed a series of failures. First, although the manufacturers of the bath hoist recommended the use of seat belt and despite one being available on Oak Ward, it was not fitted to the hoist. The carers did not use, nor did they know how to fit it correctly.

Furthermore, the investigation found that one of the assistants had not had a refresher training in the past 13 months before the incident, despite a recommendation for a yearly update. 

The HSI also found that three Medical Device Alerts (MDA) had been issued in relation to two incidents with the hoist. They recommended the use of the safety belt following a previous fatality in 2008 and that all staff to be trained in its use. Those were not implemented at the time of the incident as the safety belt was not even fitted to the hoist, even though it had been provided.

Prosecuting Crown Advocate Conrad Yates noted that an incident in 2011 identified that the use of the seat belt prevented a serious accident, made it even more difficult to understand the failure by HSSD to implement its use, particularly with the most vulnerable patients.

Finally the investigation found that both assistants were unaware of the contents of Mrs Cornish's care plan. It indicated that she preferred her personal care to be dealt with by female staff and that she had a history of aggression and hostility towards the staff. It also mentioned she could be resistive and that her posture was poor at times, meaning she required full assistance. The medical records also noted that Mrs Cornish had become rigid on three occasions during nursing interventions. Furthermore, the plan hadn't been reviewed by a staff nurse for over five weeks by the time of the incident contrary to the four-week target. One of the assistants explained he didn't always have the time to review the care plans while the other one said she had never seen one. 

A subsequent Case investigation Report by the HSS also found that there was not enough communication among the nursing staff regarding the care plans and risk assessments. It also noted staff comments that although, the care plans were accessible for all to read, they did not have enough time to do so.

Advocate Debbie Corbell, who acted as defence for the SEB, said that they publicly and unreservedly apologised to the family of the victim. She explained that the services had met with Mrs Cornish's family on several occasions and thanked them for their input. 

She told Court that changes and improvements had been made since the incident, first with a upgrade of all the hoists, which was not as a result of a deficiency with the hoist used at the time which was perfectly functional. The total expenditure for the audit of the equipment amounted to over £79,000.

She added that the SEB conducted a thorough review and internal investigation to make sure that practices across all services were the very best they can be and not simply adequate or satisfactory. An audit of all care plans was also carried out with the introduction of announced and unannounced visits to check the implementation of changes across all wards.

A change in policy regarding the dissemination of safety alerts was also introduced to make sure all staff, at all levels, can see them and act accordingly.

Handing out his sentence, Deputy Bailiff Tim Le Cocq, who was sitting with Jurats Jane Ronge and Charles Blampied, said that Mrs Cornish's death was a "wholly avoidable and unnecessary loss of her life." He noted that inadequate systems were in place and that there had been failures at all levels of management.

The Deputy Bailiff also noted that although the SEB had found itself in court on three previous occasions, it was the first time it was in relation with the HSSD. He added that many steps had clearly been taken to remedy the situation and that the court was confident this would not happen, which should be a comfort to members of the public.

He described a catalogue of failures over a significant period which led to a lack of awareness of the recognised use of the hoist. He sentenced the SEB £50,000 and ordered them to pay £10,000 in legal costs. 

Following the sentence Julie Garbutt, Chief Executive at the HSSD issued a statement. She said: "First of all I would like to express my sincere condolences to Mrs Cornish's family for their loss - on behalf of all who work in the Health and Social Services Department, I am very sorry for the failings in care in this case.

She added that while she was unable to make further comments, as the inquest into Mrs Cornish's death is forthcoming, she wanted to reassure islanders that the incident had been thoroughly investigated and a series of measures put in place to address the issues and underline the HSSD's commitment to patient safety. "I realise that this cannot change the suffering that Mrs Cornish and her family experience, although I hope the thorough investigation and actions taken to safeguard our current and future patients will bring some small comfort. Once again I'd like to offer my deepest condolences."