Following an investigation by the Health and Safety Executive for Northern Ireland (HSENI), a Belfast-based health care company, Harmony CCS Limited, were today fined £50,000 following the death of a resident who suffered injuries resulting from a fall.

The company earlier pleaded guilty to a single health and safety breach following the death of a patient at Rose Lodge Nursing home in Lisburn in 2020.

The prosecution arose following an investigation by the Health and Safety Executive for Northern Ireland (HSENI), into the fall of a resident, Mrs. Mary ‘Pat’ Thompson on 18 May 2020. The court heard that while receiving personal care, Mrs. Thompson was left sitting unattended at the edge of a bed. She subsequently fell forwards onto the floor and suffered multiple injuries. She passed away a number of days later in hospital.

Speaking after the hearing, HSENI Inspector Kiara Blackburn said: “Care plans must identify the specific care needs of each resident and should be followed by all care staff. Staff should not be reliant on informal assessments to determine a resident’s needs.

“Any changes to a resident’s needs should be adequately risk assessed, documented and the information communicated to all care staff.”

The HSENI investigation found that the care plans for Mrs. Thompson indicated that she required the assistance of two carers for safe moving, handling, and transferring activities. No formal indication was provided within these care plans as to the level of assistance Mrs. Thompson required for personal care.

On this occasion a junior member of staff was directed by a senior member of staff to provide personal care for Mrs. Thompson on her own. As a result, Mrs. Thompson was moved by one carer and left unattended at the edge of the bed from which she fell.

The investigation found that there was no formal system in place to identify whether personal care was to be carried out by one or two carers. Instead, staff relied on a daily, informal assessment of the resident’s presentation to determine their needs. This practice highlighted the failure of the company to ensure that adequate systems were in place to ensure the safety of residents, and to ensure that all staff were adequately trained and supervised to carry out their work safely.