Basildon and Thurrock University Hospitals Foundation Trust has been fined £50,000 plus £40,000 costs following the death of a patient with cerebral palsy.
The trust was sentenced today after it admitted failing to ensure the health and safety of patients in its care at a court hearing in February.
Kyle Flack, 20, died from asphyxiation at Basildon Hospital on 12 October 2006 when his head became trapped between the bottom rail surrounding his bed and the edge of the bed itself.
Mr Flack had been admitted to Basildon with a stomach complaint. During the night before he died, he was found several times lying diagonally in his bed and with his head wedged between the rails.
He was repositioned twice by nurses but later, despite concerns raised by a passing cleaner, no action was taken. Mr Flack was later found lying with his head trapped between the bottom rail and the edge of the bed. Resuscitation attempts failed.
Basildon Crown Court heard in February there had been a similar incident during an earlier stay at the hospital, resulting in Mr Flack suffering bruising, swelling and a bleeding mouth after he forced his head part way through the rails.
However, no assessment of his needs was carried out when he was admitted in 2006 and staff had no knowledge of the previous incident.
Investigations by Health and Safety Executive found the trust had no systems in place on each ward for assessing the risk to patients from bed rails.
The trust’s practice for obtaining, recording and disseminating information about Mr Flack’s needs was found to be poor. Staff did not formally share knowledge of individual patients.
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.
HSE inspector Sue Matthews said: “Simple measures should have been taken to prevent this from happening.
“This would have included a thorough bedrail risk assessment being carried out by a qualified member of staff, with input from Kyle’s mother and reference to a previous bedrail injury which Kyle suffered at Basildon Hospital in 2005.
“The use of suitable bedrails and bumpers, frequent monitoring of Kyle while the bedrails were in place and proper recordkeeping by staff would also have helped prevent this tragic death.”
Basildon and Thurrock University Hospitals Foundation Trust director of nursing Maggie Rogers said: “We fully accept and profoundly apologise for the mistakes made in the care of Kyle Flack.
“In the years since Kyle’s tragic death, we have completely reviewed the care provided to patients with learning disabilities and have put in place many improvements. This includes training for all staff, many changes to protocols and procedures and over £1m of investment to re-equip the hospital with new beds and bed-related equipment.”
A Care Quality Commission spokesperson said: “We have been looking extremely closely at the quality of care for people with learning disabilities at the trust to check that the lessons have been learned.
“On our visits, we found some progress to improve the care of people with a learning disability, but more is needed. The trust must improve staff training; communication with patients; and the way it assesses and manages safety risks.
“We have also imposed strict conditions on the trust’s registration, requiring a range of improvements across the whole trust.”