Derbyshire County Council has been fined £500,000 following the first prosecution that the Care Quality Commission has brought against a local authority since the watchdog was given powers to prosecute health and social care providers for failing to provide safe care and treatment in 2015.
The case arose out of an incident at The Grange Care Home in Eckington in which Audrey Allen, an 80-year-old former nurse, sustained injuries which led to her death.
The council, which runs the care home, had pleaded guilty treatment at an earlier hearing at Derby Magistrates’ Court on 6 June 2019 to failing to provide safe care and treatment, resulting in avoidable harm to Miss Allen.
At Chesterfield Magistrates’ Court, the council was ordered to pay a £170 victim surcharge and £5,124 costs in addition to the fine.
The court heard that Miss Allen had a documented history of falls. She was also living with dementia and other complex medical issues when she was admitted to The Grange on 3 December 2015.
Miss Allen suffered several falls and loses of balance during her three-and-a-half month stay at the care home.
The CQC said there were numerous instances where she was described as being unexpectedly on the floor. “Despite these incidents, the council, as provider of the service, failed to adequately assess and reduce the risk of her falling,” it added.
The watchdog prosecuted the council after Miss Allen suffered rib fractures during a fall on 25 March 2016 at The Grange. These fractures lacerated one of Miss Allen’s lungs, leading to a haemorrhage which caused her death on 16 April 2016 at Chesterfield Royal Hospital.
The court heard that Miss Allen fell while in a communal area at the home. Staff took Miss Allen to her bed. Although she reported pain in her left side no medical advice was sought.
The following morning, staff found Miss Allen unresponsive and they called for an ambulance. Paramedics were not informed that Miss Allen had suffered a fall the previous evening, nor were they advised that she reported being in pain.
Miss Allen was taken to Chesterfield Royal Hospital where X-rays identified rib fractures. She remained in hospital until her death just over three weeks later, on 16 April.
Ryan Donoghue, prosecuting, said: “Audrey Allen was known to be at high risk of falling, yet Derbyshire County Council failed to adequately assess or meet her needs.
“The council has accepted that its falls policy was not fit for purpose or properly implemented, that protective measures to reduce the risk of Miss Allen falling were not in place and that it should have referred her to a falls specialist.”
Summing up, Judge Jonathan Taaffe addressed Miss Allen’s family, who were in court, saying: “Miss Allen had the right to a comfortable end to a dignified life. She, her family and friends were totally let down. Derbyshire County Council fell far below the standards of safe care and treatment that Miss Allen should have been able to expect.”
Rob Assall-Marsden, interim deputy chief inspector for adult social care for CQC, said: “This was a serious failure on the part of Derbyshire County Council. As a provider of care services, it had a specific legal duty to ensure care and treatment was provided safely to Miss Allen. They failed to do this by not ensuring risks had been fully assessed, and by not implementing measures to prevent harm to Miss Allen.
“Where we find any care provider has put people using its services at serious risk of harm, we will take action to hold them to account and ensure that others can receive safe care going forward.”
Derbyshire County Council Leader Cllr Barry Lewis said: “We would like to offer our sincere condolences to Miss Allen’s family and apologise wholeheartedly for the failings that caused her death.
“In this case, our actions fell below the high standards that we expect of ourselves and we are truly sorry for what happened. The safety and wellbeing of our residents is our number one priority and we have worked extremely hard to address the issues involved in this tragic case.”
Cllr Lewis said Derbyshire had implemented a number of changes to do its best to ensure this could not happen again. These measures included:
- Reviewing and revising its Falls Policy.
- Established a Quality and Improvement Board to oversee the delivery of a quality improvement plan.
- Increasing staffing in the service.
- Implementing changes to its pre-admission assessments.
- Compulsory falls prevention training for staff.
Cllr Lewis added: “Three years on we continue to build on the progress we’ve made and a recent independent inspection of the home found evidence of improvements in the recording of falls and the admission process.
“We continue to work to improve our processes to ensure that we meet the high standards that people rightly expect of us and that residents are safe in our care.”