Operator of Worthing care home fined after 'potentially preventable' death of resident

Claremont Care Services Limited, which operates Offington Park Care Home in Worthing, was ordered to pay £24,981 after ‘failing to provide safe care and treatment’, the Care Quality Commission (CQC) said.

A case at Brighton Magistrates’ Court on Wednesday (May 17) heard that the operator failed to protect John Bowles, a person living in one of their services, from ‘significant risk of avoidable harm’.

A CQC spokesperson added: “The provider also failed to inform and apologise to Mr Bowles’ family following his death.

“Claremont Care Services Limited was fined £24,800. It was also ordered to pay a £181 victim surcharge. Costs to the Care Quality Commission (CQC) which brought the prosecution will be determined at a later date.”

At the time of the incident, Claremont Care Services Limited operated two care homes, including Offington Park Care Home in Worthing, which provided accommodation for up to 24 people, the CQC said.

The spokesperson added: “On December 25, 2019, Mr Bowles a 75-year-old male resident was admitted to the service after being discharged from hospital. When being discharged, the hospital told the home that Mr Bowles was at risk of falls.

“The provider was also made aware that Mr Bowles was taking medications which decreased blood clotting (anticoagulants). The National Institute for Health and Care (NICE) Guidelines advises that people on anticoagulants face greater risk from head injuries and should be urgently referred to hospital if they are injured in this way.

“Mr Bowles suffered an unwitnessed fall on the day of his admission, but no injury was recorded. Three days later, on December 28, 2019, he suffered another unwitnessed fall and developed a lump on his head.

"He was taken to hospital where a scan found no head injury. This was the only time medical treatment was sought for Mr Bowles following a fall.”

The CQC noted that – up to February 8, 2020, Mr Bowles ‘fell a further seven times’ – three of which caused him a head injury, but staff ‘sought no medical treatment’.

A statement read: “On the morning of February 9, 2020, he suffered another unwitnessed fall resulting in a head injury. Staff took physical observations but didn’t have any previous recordings to compare against. They offered to contact emergency services, but Mr Bowles declined, and staff complied with his wishes however, this went against NICE guidelines.

“Later that evening, staff heard a loud bang from Mr Bowles’ room. He said he banged the back of his head on the wall. Staff didn’t see an injury and didn’t seek medical treatment.

"A few hours later that night, staff found him walking in the corridor. He requested a specialist and staff offered to call emergency services but again he declined. Staff again didn’t follow NICE guidance.”

Mr Bowles sadly died the next day (February 10, 2020).

The CQC statement continued: “Staff found Mr Bowles unresponsive in bed and called 999. He was pronounced dead at hospital and was later determined to have died from a traumatic head injury.

“It was found that the service’s falls and head injury guidance didn’t advise staff to seek emergency care for people on blood thinning medication if they suffered a head injury. This is contrary to NICE guidelines.

"Mr Bowles’ care plan was also incomplete and did not reflect the number of falls he had suffered. A falls risk assessment was not completed until he’d already fallen five times.

“The provider also failed to inform and apologise to Mr Bowles’ family soon enough after the incident and his death. In doing this, the provider has failed to fulfil their duty of candour.”

The CQC said Claremont Care Services Limited pleaded guilty to failing to provide safe care and treatment to Mr Bowles – resulting in him being ‘exposed to significant risk of harm’ which ‘ultimately led to his death’. On top of the £25,000 fine, the provider was made to pay £800 for ‘failing in their duty of candour’.

Natalie Reed, CQC deputy director of operations in the south said: “Our sympathies are with Mr Bowles’ family following his potentially preventable death.

“People receiving care and treatment have the right to expect that any risks to their safety will be effectively managed and families or loved ones will be informed in an open and transparent manner as soon as possible.

“The failure of Claremont Care Services to manage Mr Bowles’ risks and ensure that they were following national guidance essential to his safety and wellbeing was unacceptable. Furthermore, the lack of openness and transparency shared by Claremont to his family just added distress.

“The majority of care providers do an excellent job. However, when a provider puts people in its care at risk of harm, we will take action to hold them to account and to protect people. 

“I hope the outcome of this prosecution reminds care providers of their duty to assess and manage all risks to ensure people are kept safe and families and loved ones are kept informed.”