Lisburn: Care home firm fined £50k after woman’s death

The accident was investigated by the Health and Safety Executive for Northern Ireland (HSENI).

It found that Mrs Thompson had care plans in place which indicated she required the assistance of two carers in order to stay safe while being moved.

However, no formal indication was provided in the care plans as to the level of assistance Mrs Thompson required for personal care.

On the day of the fall, a junior staff member was directed by a senior staff member 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,” a HSENI statement said.

The investigation found 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.

The HSENI said this informal assessment “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”.

Speaking after the court 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.”