£100k fine for care company after tragic death of woman
A supported housing company has been fined £100k after a disabled woman in their care died after choking on a marshmallow.
Shirley Breeze, who had severe learning disabilities, as well as being diagnosed with epilepsy and dyspraxia was in the care of Ark Housing Association Limited when the incident happened at her home address in Cowdenbeath, Fife.
Kirkcaldy Sheriff Court heard how the 64-year-old was given the marshmallow – which was an unsuitable food item for her prescribed diet – by one of the company’s support workers on 30 November 2019.
Miss Breeze began to choke soon afterwards and although the support worker correctly followed first aid procedures, was unable to dislodge the marshmallow. The support worker carried out CPR until paramedics arrived to provide additional emergency assistance. Paramedics were successful in removing the marshmallow, but Miss Breeze then suffered two cardiac arrests and a seizure, which led to her being placed in an induced coma. She passed away on 2 December 2019.
An investigation carried out by the Health and Safety Executive (HSE) found that Miss Breeze had been the subject of an assessment by Speech and Language Therapy following a prior choking incident. It was advised that she be placed on ‘a Texture Type E (soft) diet’. There was evidence that requirements of her Type E diet were not known, understood, or implemented by all of her support workers. Ark Housing Association Limited failed to provide support workers with adequate training to ensure that all aspects of a Type E diet, now known as an IDDSI Level 6 diet, were understood and followed.
Ark Housing Association Limited pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 and were fined £100,000.
Speaking after the case HM Inspector, Kerry Cringan said “This was a tragic and deeply upsetting incident for all involved, particularly the team who had cared for Miss Breeze for many years.
“Ark Housing Association Ltd had identified the risk of choking and had taken steps to ensure the care plan reflected this risk.
“However, they failed to provide support workers with adequate training so that they understood the foods textures that would pose a challenge for Miss Breeze.
“This failing ultimately led to the death of a vulnerable person.”
Notes to Editors:
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
More information about the legislation referred to in this case is available.
A Dorset man who found his friend and neighbour crushed to death under a car has urged mechanics and car enthusiasts not to cut corners.
Leslie House, 61, a self-employed agricultural engineer who was only months from retirement, was repairing a Land Rover Freelander for a customer in May 2020.
His neighbour Terry Bishop, a retired safety consultant in the nuclear industry, was asked to go and check on Leslie, known to everyone as Les, who was working on the vehicle on his driveway at Higher Muckleford near Dorchester.
Leslie House, with his dog Ebby
“Nothing looked out of the ordinary at first,” said 65-year-old Terry. “I called out to Les several times but he didn’t respond. When I reached the front of the vehicle I could see Les’ legs sticking out with his feet flopped over to the sides and he was unresponsive to me.
“I grabbed his legs and tried to pull him out but couldn’t move him. It was then that I noticed the vehicle was off the wooden blocks he had been using. I tried to push the vehicle backwards up onto the blocks but it was too heavy. I immediately rang the emergency services for help.
“I felt for a pulse, but there was none and I suppose at that point I knew he was dead, but it doesn’t stop you trying does it? I ran to another neighbour for help, and she together with myself and my daughter again tried to move the vehicle back up onto the blocks and off Les, but the Land Rover was just too heavy.”
Les was pronounced dead at the scene by the emergency services. Terry told police that he found the vehicle’s handbrake was not on.
A single man known widely throughout the community, Les lived, together with his dog Ebby, next door to his mother June House. In the last few years of his life he had become her primary carer. She suffered from an untreatable degenerative spinal condition which meant she was in constant pain, largely immobile and virtually house-bound.
The task of breaking the tragic news to June fell to Terry. He said: “It was a surreal experience. It just didn’t sink in, either to June or myself.”
Terry Bishop, in front of the scene of the incident
Les House was known for his expertise in maintaining Land Rovers following decades of experience gleaned from working with a nearby servicing and parts specialist. “There were very few faults that he had not previously come across or didn’t know how to overcome,” said Terry.
Reflecting on what went wrong on the day of Les’ death, Terry said: “The job he was doing was probably something he would have done hundreds and hundreds of times before. But for some reason on that day the handbrake wasn’t on. Truthfully, he shouldn’t have been using wooden blocks either.
“At the end of the day, this tragic accident was down to Les. It was his mistake by putting the vehicle up on those blocks. That said, given the kind of man he was, I know Les would want others to learn from his mistake and prevent further loss of life.
“There must be hundreds of near misses out there, where someone manages to get out just in time. But the simple message to the trade and car repair enthusiasts alike, is don’t cut corners. Cutting corners kills.”
Les took a keen interest in all things rural, with his real passion being vintage tractors and ploughing. He was a long-standing member of the West Dorset Vintage Tractor and Stationary Engine Club (DVTSEC), serving on its organising committee for many years. He was also a member of The Society of Ploughmen.
He was a staunch supporter of local charities. In addition to the extensive donations made by DVTSEC to a wide-range of causes and groups every year, Les and two friends organised an annual ploughing match, the proceeds of which were given to support the Dorset and Somerset Air Ambulance, a charity both he and his mother were firm proponents of.
“Les was someone I knew for 20 years. During that time we had got to know one another well and become good friends. We often popped into one another’s houses for a cup of coffee and a chat.
“He was on the cusp of retiring and had big plans. He was actually planning some projects with myself. At the time of his death, the country was in the middle of a national lockdown, but Les was raring to get going as soon as it ended.
“I know my friend lived his life the way he wanted, but the way it ended for him, which was so avoidable, really saddens me. I still miss him popping his head up over the garden fence for a chat or offering me some eggs.”
Les’ mum June died in June 2021. “I firmly believe Les’ passing hastened her end,” reflected Terry.
The death of Les House was raised with the Health and Safety Executive (HSE) but it was not reportable under the RIDDOR framework, so no HSE investigation was carried out.
The workplace regulator did however submit a report to the Coroner for Dorset, who, after an inquest, returned a verdict of accidental death.
Never work beneath a vehicle that is only supported on jacks:
Use axle stands that are in good condition and inspected every year
Use stands on firm, level ground and securely located under a strong point on the vehicle
Securely chock wheels remaining on the ground
Do not exceed the rated capacity of the stand
Never work beneath a cab or tipping trailer unless it is propped:
Always prop cabs, trailers etc that could drop under their own weight
The prop should be locked in position before gaining access
If there is no prop fitted, or if one is fitted but you are unsure it will be effective, provide your own
Never crawl beneath a vehicle fitted with air suspension unless it is properly supported:
Prevent movement of air suspension, either by using suitably rated props or stands to prevent the chassis lowering or by deflating the system
Don’t tamper with the ride height for the purpose of recovery or repair
Notes to editors
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
Mechanics warned of the life-threatening dangers of working under vehicles
Twenty-one workers in motor vehicle repair industry killed in last five years, HSE figures show.
More than half of these deaths (13) were caused when work took place under a vehicle that wasn’t properly supported.
Mechanics urged to challenge “this will only take me a minute” culture.
Classic Motor Cars Ltd supports HSE’s call for better safety with motor vehicles.
Leading voices in motor vehicle repair have teamed up with the Health and Safety Executive (HSE) to warn of the dangers of working under vehicles without proper equipment.
Figures recorded by HSE in the five years up to March 2022 show that 13 workers in the motor vehicle repair industry were killed when work took place under a vehicle that wasn’t properly supported. Since April 2022, HSE has become aware of another four cases of workers being crushed to death by an incorrectly supported vehicle.
Leslie House, 61, was working outside his home in Dorset in May 2020 when he was crushed to death by the Land Rover Freelander he was underneath, which had rolled off the wooden blocks Les used to prop it up.
Leslie House, with his dog Ebby
Les was a self-employed agricultural engineer, repairing the car for a customer, and was only months from retirement. He was pronounced dead at the scene by the emergency services.
Official and anecdotal reports of a wide range of working practices gone wrong are leading to fears mechanics and enthusiasts are putting their lives in danger routinely.
Classic Motor Cars (CMC), experts in classic car restoration with their own dedicated workshop, are supporting HSE’s call to the industry.
“I am saddened but not surprised to hear of these tragedies,” said Tim Griffin, Production and Engineering Director at CMC.
“The situation could get worse as people and businesses may cut costs with higher energy bills”, said Tim, who oversees a team of experienced engineers and technicians. “My plea is that it’s never a good time to cut corners – the stakes are too high.”
Fiona McGarry, an HSE inspector who works with the motor vehicle repair trade said: “One death is too many – to us, these tragedies could easily have been avoided, but they keep happening. Sadly, the phrase we hear too often is ‘this will only take me a minute’. It is crucial the correct equipment is used when working under vehicles.”
HSE’s Fiona McGarry
The annual death rate in the motor vehicle repair industry is 1.62 deaths per 100,000 workers – around four times the average rate across all industries. In total, 21 workers in the motor vehicle repair industry have been killed in the last five years – 13 of which were caused by work under a poorly supported vehicle.
As Britain’s workplace regulator, HSE is officially notified of work-related fatal and certain non-fatal accidents across England, Scotland and Wales. Alongside the 13 deaths, there are many more non-fatal injuries and near misses following work under poorly supported vehicles.
Fiona McGarry continued: “While our figures relate specifically to motor vehicle repair, work on vehicles happens across industries including transportation and agriculture. We all need to ensure work on vehicles is carried out safely, regardless of sector.
“We are becoming increasingly concerned about the scale of the issue. Failure to learn from near misses or injuries will risk lives.
“Some of these issues relate to smaller garages – places that are hard to reach. We have always had a strong relationship with the motor vehicle repair sector, and we respect the expertise of these small businesses.
“But as the issue has persisted, we needed to raise awareness of the issue together. It is therefore important CMC and the Garage Equipment Association are encouraging everyone who works on vehicles – at work, or at home – to check HSE’s guidance.
“There are simple control measures which can avoid tragic cases like that of Les House.”
Julian Woods, CEO of the Garage Equipment Association said: “We consider health and safety to be of the upmost importance to our industry and any loss of life should be considered an unacceptable situation.
“We drive to improve health and safety not only for our members but in the industry as a whole. It’s all too easy to think it will never happen to me or it will only take a second to sort, so skip safety items to get the job done quickly, but these statistics are unacceptable.
“We all need to be thinking of not only ourselves but everybody’s health and safety. If we see an unsafe act we should raise it up and not just turn a blind eye and keep walking.”
HSE’s advice to the trade:
Never work beneath a vehicle that is only supported on jacks:
Use axle stands that are in good condition and inspected every year
Use stands on firm, level ground and securely located under a strong point on the vehicle
Securely chock wheels remaining on the ground
Do not exceed the rated capacity of the stand
Never work beneath a cab or tipping trailer unless it is propped:
Always prop cabs, trailers etc that could drop under their own weight
The prop should be locked in position before gaining access
If there is no prop fitted, or if one is fitted but you are unsure it will be effective, provide your own
Never crawl beneath a vehicle fitted with air suspension unless it is properly supported:
Prevent movement of air suspension, either by using suitably rated props or stands to prevent the chassis lowering or by deflating the system
Don’t tamper with the ride height for the purpose of recovery or repair
Notes to editors
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
Based in Shropshire, Classic Motor Cars provide customers with a range of services from full nut and bolt restorations to storage. The company workshops cover over 40,000 sq. ft, with highly trained team members, all keen to provide their expert assistance. From spare parts and routine servicing to full restorations, the company has been trusted with the country’s most prestigious vehicles.
Bupa Care Homes fined £400k after falling tree crushes child
A care home provider has been fined £400k after an eight-year-old girl suffered catastrophic injuries when a tree fell on her.
West Hampshire Magistrates Court heard that on 8 July 2021, the girl was out for an evening jog with her father. As she was running on a pavement outside the entrance to the care home, a lime tree fell on her. She suffered serious crush injuries and her leg had to be amputated. It was subsequently found that the tree was diseased with a common fungus and had likely been rotting for several years prior to the accident.
The lime tree fell on the girl as she was running along a pavement outside the entrance to the care home (HSE)
An investigation by the Health and Safety Executive (HSE) found that, over a number of years, Bupa Care Homes had failed to have in place a strategy to manage trees, including adequate risk assessment, proactive surveys, inspections, and monitoring of trees, to identify where remedial work may have been required to prevent risk of the tree falling.
The lime tree fell on the girl as she was running along a pavement outside the entrance to the care home (HSE)
Bupa Care Homes pleaded guilty to a breach of Section 3(1) of the Health and Safety at Work etc. Act 1974 and received a fine of £400,000. The company was also ordered to pay costs of £3,275 and a victim surcharge.
HSE Inspector Natalie Pomfret said: “This was a tragic and wholly avoidable incident, caused by the failure of the company to have in place suitable arrangements for managing trees on their premises, and failure to ensure that the trees were properly inspected and maintained.”
Notes to Editors:
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
More information about the legislation referred to in this case is available.
Guidance about managing the risk from falling trees is available.
Wine company fined £800k after HGV driver killed at Salford depot
A wine and drinks supplier has been fined after a visiting HGV driver was killed after being hit by a forklift truck at its depot in Salford.
John Fitzpatrick was waiting for his trailer to be loaded at Kingsland Drinks Ltd in Irlam on 19 August 2020 when tragedy struck. The 59-year-old, form Oldham, suffered serious head injuries in the incident and died in hospital having never regained consciousness.
A still from the CCTV at the Kingsland Drinks depot in Irlam (HSE)
In a victim personal statement read out at Manchester Magistrates Court, his partner Paula Fitzpatrick, said how his death had affected their family.
“I cannot really explain what we have lost without describing the kind of person John was,” she said.
“John was a joyful character, full of life, and often described as the life and soul of the party.
“He would talk to anyone and I would often lose him for a couple of hours when he went to the local shop as he would be talking to all the neighbours on the way.
“He was that kind of person – a very hardworking man who would do all the DIY around the house and that included all the family’s odd-jobs.
“At the time of his death, we were planning how our future would look.”
An investigation by the Health and Safety Executive (HSE) found the company had failed in a number of areas. The risk assessment was out of date and not fit for purpose, and there was no pedestrian and vehicle segregation in place in the loading area. Visiting drivers were not given clear information about site safety.
At a sentencing hearing at Manchester Magistrates’ Court on 25 January, Kingsland Drinks Ltd of The Winery, Fairhills Road, Irlam, Manchester, pleaded guilty to breaching section 2(1) and 3(1) of the Health and Safety at Work Act. They were fined £800,000 and ordered to pay costs of £5,614.30.
Speaking after the hearing HSE Inspector Sharon Butler said: “This death would have been prevented if clear controls had been in place for visiting drivers.
“Companies who have loading areas need to provide information and instructions to visiting drivers and have clear segregation in place to ensure the site is safe for all who use it.
“Easy steps can be taken to reduce the risk of visiting drivers becoming injured on site.”
Notes to Editors:
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
More information about the legislation referred to in this case is available.
