Basildon and Thurrock University Hospitals NHS Foundation Trust has been fined £50,000 and £40,000 costs, following the tragic death in its care of a severely-disabled young man with cerebral palsy.
Kyle Flack died from asphyxiation at Basildon University Hospital, early on 12 October 2006, after his head became trapped between the bottom rail surrounding his bed and the edge of the bed itself. During the night before he died, he was found several times lying diagonally in his bed and with his head wedged between the rails. He was repositioned twice by nurses but later, despite concerns raised by a passing cleaner, no action was taken. In February when the Trust admitted the breaches, Basildon Crown Court heard there had been a similar incident during an earlier stay at the hospital. Kyle had suffered bruising, swelling and a bleeding mouth after he forced his head part way through the rails. Despite this, no assessment of his needs was carried out when he was admitted in 2006 and staff had no knowledge of the previous incident. Kyle was placed in a single room without one-to-one care and only monitored at irregular intervals. Investigations by HSE found the Trust had no systems in place on each ward for assessing the risk to patients from bed rails. People with cerebral palsy are known to be particularly at risk of entrapment and the issue was highlighted in Department for Health guidelines published in 2001. The Trust’s practice for obtaining, recording and disseminating information about Kyle’s needs was found to be poor. Staff did not formally share knowledge of individual patients. There was no system in place to alert staff to his particular needs or habits, instead staff were relied on to remember him from previous visits or to retrieve records to read through his past medical notes. In addition, despite Kyle’s small size he was placed in a bed with adult spacing bed rails. The NHS Foundation Trust was sentenced after it admitted failing to ensure the health and safety of patients in its care, breaching Section 3(1) of the Health and Safety at Work Act 1974. HSE Inspector Sue Matthews said: “Simple measures should have been taken to prevent this from happening. This would have included a thorough bed rail risk assessment being carried out by a qualified member of staff, with input from Kyle’s mother and reference to a previous bed rail injury which Kyle suffered at Basildon Hospital in 2005. The use of suitable bed rails and bumpers, frequent monitoring of Kyle while the bed rails were in place and proper record-keeping by staff would also have helped prevent this tragic death.”
