Care home fined £50,000 after man with dementia dies in car park on Boxing Day
Hugh Kearins, a resident of Chester Park Care Home in Glasgow, was found outside just off Lambhill Street, in the freezing cold, at around 7am in December 2022.
The Health and Safety Executive (HSE) said that the 77-year-old managed to leave the care home via a series of stairways and fire doors, with an inspector counting 320 steps from Mr Kearins' room to the car park.
Oakminster Healthcare Limited admitted a health and safety breach at Glasgow Sheriff Court on July 23 and was fined £53,750. HSE via Supplied Inside Chester Park Care Home is made up of a series of internal gates and stairways. HSE via Supplied
Kearins, who had dementia, had been living in a room within the Clyde Unit of the home since 2012.
HSE's investigation found that the company had failed to install a safe system of work and that the incident was 'completely avoidable'.
Once the door was noted to be insecure, it was confirmed by the care home manager that a member of staff should have initiated a head count of all residents to ensure their safety.
This was not carried out.
Mr Kearins' records extensively noted he was at risk of 'absconding or wandering' and it was part of his care plan that he be checked or monitored every hour. HSE via Supplied The white cross (bottom left corner) marks where Mr Kearin's body was found. HSE via Supplied
The court heard that the failures of the alarm door reactivation would not have occurred if not for four individual errors, including the member of staff closing the internal fire door without further action, and the fire alarm for the internal fire door being deactivated.
The incident was also blamed on the staff member's error in leaving the unalarmed external fire door insecure and the overall actions of both the senior care assistant and the care assistant.
Both carers were subsequently dismissed from their employment following disciplinary interviews a few days later.
HSE said they are subject to investigation by the Scottish Social Services Council.
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.
'We will always take action against those who fail in their responsibilities.'
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