A 77-year-old dementia patient at a Glasgow care home left the premises unnoticed after gaining access to unsecured doors. A series of preventable failures led to his death and a fine of £53,750 for the Company.
On the night of 26 December 2022, 77-year-old Hugh Kearins left Chester Park Care Home in Glasgow without anyone noticing. Hugh had dementia and was living in a room within the Clyde Unit of the home since 2012. Staff knew he had a tendency to wander, and his care plan said he should be checked every hour. But that night those checks did not happen. He managed to get through an internal fire door that had its alarm switched off. Just beyond it, an external fire door was also left insecure and without an alarm. With nothing stopping him, Hugh walked outside into the freezing night.
By the time staff found him early the next morning he was lying in the car park. The car park is only 320 steps from his room. He passed away during the night.
Health and Safety Executive (HSE) highlighted several failings on the part of Chester Park Care home:
Hugh’s care plan said staff should check on him every hour to make sure he was safe. On that night those checks just did not happen
The inside fire door had an alarm to warn staff if someone went out. But it was deactivated, so nobody knew when Hugh opened it.
After the first door there was another outside door, it did not have an alarm and was not locked properly, so Hugh could walk straight out.
A staff member saw a door open but just closed it. They did not count to see if everyone was still there.
The actions of both the senior care assistant and the care assistant who had responsibility for Mr Kearins’ care were also found to have falsified records, stating that they had performed tasks involving him at a time when he was in fact no longer in the home.
Staff did not know Hugh had left until after he was found in the car park in the next morning.
Oakminster Healthcare Limited, of Lambhill Street, Glasgow, pleaded guilty to breaching Sections 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The company was fined £53,750.
To prevent similar incidents, care homes should keep all exit doors secure and ensure alarms are always switched on and working. Staff must follow each resident’s care plan exactly, including regular safety checks for those at risk of wandering. Any open or insecure doors should be investigated immediately, with a headcount done to make sure all residents are present. Records must always be accurate and truthful, so problems are identified and resolved immediately. Regular staff training and equipment checks should be carried out to ensure all safety measures are in place.
