Care home firm fined for 'completely avoidable' death of vulnerable patient

A care home provider has been fined more than £50,000 and criticised by the workplace health and safety watchdog for the “completely avoidable” death of an elderly patient.

Hugh Kearins, who had dementia, managed to leave the Chester Park Care Home in Glasgow via a series of stairways and fire doors, despite the care home’s records showing a clear risk that he might abscond.

The vulnerable 77 year-old was able to walk more than 300 steps from his room, passing through a series of internal gates and stairways, before making his way out a fire door to a car park, where his body was found at around 7am on Boxing Day 2022.

An investigation by the Health and Safety Executive (HSE) found the company behind the care home had failed to have a safe system of work in place. The firm’s care plan for Mr Kearins specified that he be checked or monitored every hour.

Hugh Kearins exited the care home via a fire door, marked by a red cross. His body was found in a nearby car park, marked by a white cross. Picture: HSE | HSE

A senior care assistant and a care assistant who had responsibility for his care were found to have falsified records, stating that they had performed tasks involving him at a time when he was no longer in the home. Both were unaware he was absent until his body was found just off the city’s Lambhill Street.

The HSE said it was unable to obtain corroborated evidence of who was last to use an internal fire door at the property prior to Mr Kearins, who is thought to have exited through it just before 1am. The same door was closed around an hour later by an unknown member of staff carrying out routine checks.

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It was confirmed by the care home manager that once the door was noted to be insecure, the member of staff should have initiated a head count of the residents. However, this was not carried out.

The HSE said the management failures in respect of the alarm door reactivation were not causative of Mr Kearins’ death and would likely not have even come to light but for four individual errors: the unidentified member of staff who closed the internal fire door without further action; the deactivated fire alarm for the internal fire door; the unidentified member of staff who left the unalarmed external fire door insecure; and the actions of both the senior care assistant and the care assistant.

The fire door through which Mr Kearins was able to exit the care home. Picture: HSE | HSE

The care home’s parent firm, Glasgow-based Oakminster Healthcare Ltd, which owns four other homes, was fined £53,750 at Glasgow Sheriff Court on 23 July after it pleaded guilty to breaches of the Health and Safety at Work etc. Act 1974.

HM Inspector Amna Shah said: “This incident was completely avoidable. It is hugely concerning that a vulnerable man was able to walk so far and through so many doors without being noticed. We counted he had walked more than 300 steps. The fact this incident happened at Christmas time makes it all the more tragic.”

A spokeswoman for Chester Park Care Home said that following the incident, it reviewed health and safety proceures, implemented rigorous staff training, and strengthened security protocols to ensure “such a tragedy can never happen again.”

She added: “Ensuring the safety and wellbeing of those in our care is our highest priority, and we deeply regret that, on this occasion, we fell short of that commitment.”