Health board fined £220,000 following death of patients

Lothian Health Board has been fined £220,000 for safety breaches, following the death of two vulnerable patients.

Both were being cared for at the Western General Hospital in Edinburgh at the time of their deaths.

On 29 October 2017, one of the patients, then aged 55, was in the care of the Neurosurgery Ward following an attempt to take his own life in which he sustained a head injury. While in the care of the ward he fell more than 11 metres to his death from a second-floor window. The window in his room was not restricted to the required 100mm opening gap.

The Health and Safety Executive (HSE) investigation revealed a failure to ensure that the patient was in a room which had windows that had been suitably restricted.  The patient had undergone surgery which can cause confusion, delirium, and anxiety. It was considered to be foreseeable that patients in a state of confusion could be at increased risk.

On 23 January 2021, a second patient, then aged 79, was being cared for on the Medial Assessment Unit.  He was presenting with hallucinations, confusion, distress and showing signs of delirium. After multiple attempts to abscond over the following days, he left the ward and was found some five hours later in the hospital canteen preparation room having fallen from a first-floor window. He did not regain consciousness and his condition declined until he sadly passed away on 8 February 2021.

One of the patients was found some five hours later in the hospital canteen preparation room having fallen from a first-floor window

Plans to transfer the patient to a secure ward to manage his condition had been considered. However, at the time of his admission the transfer of patients between different wards in the hospital was strictly controlled in order to reduce the risks of Covid infections. He was therefore not transferred to a more suitable ward with the necessary security facilities to prevent him from absconding.

At Edinburgh Sheriff Court on 19 March 2024, Lothian Health Board of Waterloo Place, Edinburgh pleaded guilty to breaching Regulations Section 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. They were fined £45,000 in relation to the first incident and £175,000 for the second.

Speaking after the case, HSE inspector Kerry Cringan said: “Two vulnerable gentlemen who were in hospital to receive care lost their lives in these tragic incidents. Lothian Health Board failed to ensure the risks patients of falling from windows were adequately managed.

“All companies operating in the health and social care sector are required to ensure that systems of work are in place to ensure those in their care are safe.  The risk of falls from windows is well-known and there are standards for opening sizes that must be achieved.  HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

Notes to Editors:

  1. 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.
  2. More information about the legislation referred to in this case is available.
  3. Further details on the latest HSE news releases is available.



Metal processing firm fined after man suffers life changing injuries

A metal processing company has been fined £12,000 after an employee sustained life changing injuries at an incident at a premises in the Oldbury in the West Midlands.

Independent Slitters Limited carries out metal slitting at the facility – a process that involves coils of metal being split into various lengths. On 3 May 2022, 53-year-old Peter Daniels, husband and father of one, had a finger severed and a de-gloving of his right hand.

Guidance by the Health and Safety Executive (HSE) says employers should consider how workers use machinery and ensure it remains safe to use.

The worker had a finger severed in the incident at the company’s Park Street facility in Oldbury

Birmingham Magistrates’ Court heard Mr Daniels was in the final stages of setting up one of the slitting lines operated by the company at its facility on Park Street when the incident took place. His right hand was degloved and his middle finger badly damaged. He spent 11 days in hospital, undergoing several surgeries, which included the amputation of the middle finger as well as skin grafts.

An HSE investigation found the company did not have in place a system of work to ensure that the activity of setting and checking the blades on the slitting head rollers could be carried out safely. The risk assessment for the wide slitting line was not suitable and sufficient and did not consider the risks to employees when setting the blades.

Independent Slitters Limited of Park Street, Church Bridge, Oldbury, Warley, West Midlands pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc Act 1974. On 18 March 2024, the company was fined £12,000 and ordered to pay costs of £4,592.

After the hearing, HSE inspector Sarah Smewin commented: “The injuries that Mr Daniels suffered have impacted on all aspects of his life and resulted in him having to undergo numerous operations.

“The risks arising from working near to the dangerous moving parts of machinery are well known. Employers must assess their workplace for these risks and act to ensure that effective measures are in place to prevent access to dangerous, moving parts of machinery.”

Notes to Editors:

  1. 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.
  2. More information about the legislation referred to in this case is available.
  3. Further details on the latest HSE news releases is available.
  4. Guidance on working safely with machinery is available.

 




Pork pie maker fined £800,000 after two workers lose fingers

A company that specialises in making pork pies has been fined £800,000 after two young workers lost fingers in incidents at two different Nottingham bakeries.

Pork Farms Ltd, which makes other savoury goods such as quiches, at several sites across England, was given the fine after both workers were injured just weeks apart at the end of 2022.

The first incident took place on 16 November when a 22-year-old worker had his hand trapped while trying to clear a blockage on a conveyor at the firm’s Tottle Bakery on Dunsil Drive. He had to have a finger amputated after his hand was trapped between a chain and sprocket on a conveyor at the site.

However, just weeks later, on Christmas Eve, Mahamad Hassan, who was just 19, suffered similar injuries at Pork Farms Limited’s Riverside Bakery. The teen also had a finger amputated as a result of coming into contact with a rotating shaft on a conveyor.

An x-ray image of Mahamad Hassan’s left hand

Nottingham Magistrates’ Court heard that the company had failed to ensure that the conveyors involved in both incidents were adequately guarded.

An investigation by the Health and Safety Executive (HSE) found that dangerous parts of both conveyors were accessible at the time of each incident. At the Tottle Bakery, an unsuitable interlock was used on a hinged guard over a chain conveyor system and an inadequate inspection and maintenance regime led to this interlock failing. The chain conveyor automatically moved as he tried to adjust the position of the chain following a blockage in the area.

At the Riverside Bakery, a section of the driveshaft of a lineshaft style conveyor was unguarded and spacing of the rollers was sufficient for a persons arm to pass through and reach the driveshaft below. Mr Hassan was injured when his arm went between the rollers and his gloved hand became entangled in the rotating driveshaft.  In addition to physical guarding issues, there was no warning system to give notice that the conveyor was about to start working and emergency stop controls were not readily accessible.

Pork Farms Limited, of Queens Drive, Nottingham, pleaded guilty to breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc. Act 1974.  The company was   fined £600,000 for the incident at the Tottle Bakery and £200,000 for the incident at the Riverside Bakery. The company was also ordered to pay costs of £6,482 at Nottingham Magistrates’ Court on 18 March 2024.

Speaking after the hearing, HSE inspector Tim Nicholson said: “Both of these incidents were completely preventable.

“They left two young men with injuries that they will carry with them for the rest of their lives.

“Companies shouldn’t overlook important machinery safety basics, including provision and maintenance of adequate guards and protection devices, to ensure that access to dangerous parts of machinery is prevented.

“Companies should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

 

Notes to Editors:

  1. 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.
  2. More information about the legislation referred to in this case is available.
  3. Further details on the latest HSE news releases is available.
  4. Guidance on working safely with machinery is available.



Major pizza maker fined £800,000 after two workers caught up in machinery

One of the nation’s largest producers of supermarket pizzas has been fined £800,000 after two workers suffered serious injuries at its factory in Bolton.

Stateside Foods Limited produces millions of pizzas each year, supplied to major UK supermarkets. The company was hit with the fine after the employees were caught up in machinery at the Westhoughton site in two separate incidents during 2020.

Bolton Crown Court heard how one man had his arm drawn into an inadequately guarded conveyor belt at the Lancaster Way factory, on 8 January 2020. The injury to his arm resulted in the removal of muscle and required a skin graft. He has not returned to work since the injury and has been diagnosed with hypersensitivity in the affected arm.

Stateside Foods produce millions of pizzas each year

Following on from this, on a night shift just nine months later, father of two Andrew Holloway had part of his middle figure severed after his hand was drawn between a roller and a conveyor belt on 14 October 2020. The acting team leader had been told of an issue on the production line and gone to investigate when the horrific incident happened.

“My right hand was drawn into the roller on the machine and when I pulled my hand out my fingers were hanging off,” he said.

“I was taken to hospital and was in and out of consciousness due to the shock and pain I was suffering.

“The pain was unbearable after the initial shock wore off; I have never experienced pain this bad in my life before.

“After I woke from the first operation, the surgeon informed me that he could not save my middle finger and had to remove the top section. They managed to save my ring finger by inserting a wire into it.”

Mr Holloway required a second operation to remove more of his middle finger as the tissue had not healed properly.

“I was unable to care for my three-year-old son after the accident as I couldn’t even get myself dressed let alone a three-year-old,” he added.

“I suffer with pain every day due to the accident; my fingers are stiff and very sensitive; every winter is unbearable due to the cold.

“My favourite hobby used to be Art, which I really enjoyed, but I cannot do this for more than five minutes now. Even simple things, like holding a knife and fork when eating can be difficult.

“This has been the worst period of my life by far, not only have I suffered but so have my family.”

Andrew Holloway had part of his middle figure severed after his hand was drawn between a roller and a conveyor

Although Mr Holloway returned to work after a six-month absence he left after just a couple of days – which resulted in him starting his career again.

An investigation by the Health and Safety Executive (HSE) found the company did not adequately guard their machinery, did not provide suitable and sufficient checks to ensure that their protective measures were working effectively, and allowed the disabling of guarding systems and access to dangerous parts of machinery.

Stateside Foods Limited of Lancaster Way, Westhoughton, Bolton, pleaded guilty to breaching Section 2 (1) and 3 (1), of the Health and Safety at Work etc Act. The company was fined £800,000 and was ordered to pay £5,340 costs at a hearing on 15 March 2024 at Bolton Crown Court. The prosecution was brought by HSE enforcement lawyers Sam Crockett and supported supported by senior paralegal officer Stephen Parkinson.

The company was fined after two employees sustained injuries in 2020

After the hearing, HSE inspector Leanne Ratcliffe said: “This is one of the country’s major food companies.

“The injuries sustained by both of these workers has been truly life changing.

“This case should send a message to industry about how important it is understand the risks of bypassing guarding arrangements, and to re-evaluate their own guarding arrangements and procedures to eliminate any access to dangerous parts of machinery.

“We will always be prepared to take action when companies fall short of their duties and responsibilities to protect their staff.”

HSE Enforcement Lawyer Kate Harney presented the case at Bolton Crown Court.

 

Notes to Editors:

  1. 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.
  2. More information about the legislation referred to in this case is available.
  3. Further details on the latest HSE news releases is available.
  4. Guidance on working safely with machinery is available.

 




Construction firm fined after worker dies from fall

A construction company in Kent has been fined after a sub-contractor fell and died from his injuries.

Mark Tolley, 51, fell nearly two metres through an opening in a scaffold on 5 July 2017 while working on the construction of six houses on Smarden Road in Kent.

He sustained several broken ribs and serious internal injuries including a punctured lung. He later died on 13 July 2017.

Mr Tolley had been installing vertical hanging tiles on one of the new properties when he fell 1.8 metres through an unguarded opening in the scaffold and landed on the ground below.

An investigation by the Health and Safety Executive (HSE) found Amberley Homes (Kent) Ltd, the principal contractor for the project, had not appointed a person with the necessary skills, knowledge, experience and training to manage the construction site. The company had not ensured that a safe working platform on the scaffold was maintained throughout the different phases of the project. Access to and from the first lift working platform was unsafe as multiple openings had been made which could subsist for several weeks. The openings were unguarded and therefore there was a significant risk of falling circa 1.8 metres from the working platform.

Amberley Homes (Kent) Ltd did not control the site effectively. Its monitoring was ineffective as it did not act on concerns raised by its safety consultant when he drew the problems with site management.

HSE guidance states principal contractors must plan, manage, monitor and coordinate health and safety in the construction phase of a project. More on this can be found at: Construction (Design and Management) Regulations 2015 (hse.gov.uk)

Amberley Homes (Kent) Ltd, of London Road, Sevenoaks, Kent, entered a guilty plea to breaching Regulation 13(1) of the Construction (Design and Management) Regulations 2015 during a trial at Maidstone Nightingale Court in January 2024. The company was fined £25,000 and ordered to pay £83,842.34 in costs at Canterbury Crown Court on 15 March 2024.

HSE principal inspector Ross Carter said: “This tragic death could have been so easily avoided by implementing suitable site management to ensure that the scaffold was appropriately adapted by competent persons for the needs of the different sub-contractors.

“This case highlights that principal contractors should be aware that HSE will not hesitate to take appropriate enforcement action against those who fall below the required standards and do not plan, manage and monitor the construction phase effectively.”

Notes to Editors:

  1. 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. hse.gov.uk
  2. More about the legislation referred to in this case can be found at: legislation.gov.uk/
  3. HSE news releases are available at http://press.hse.gov.uk