Mr Lovegrove had severe mental impairment. He was registered blind and had 75 per cent deafness in both ears. He had poor speech with limited vocabulary and communicated with staff using the Makaton system of signs and signals.
He was classed as a high risk patient because he was prone to aggression which included the destruction of property and violence towards both staff and himself.
Between June 2005, when he first moved to Cedar Vale from Rampton Hospital, and May 2006, there were 95 recorded incidents involving Mr Lovegrove with restraint being applied in 32 cases.
Nottingham Crown Court was told during a two-day hearing (28 and 29 April) that minutes before his death he had been restrained for a short period of time by three support workers in the corridor after making a grab for two of them. After this, one of the staff took him back to his room to avoid further incident, one remained in the corridor and one went to the kitchen.
This left Mr Lovegrove in his room with one support worker. Mr Lovegrove grabbed him and pulled him down on top of him. The support worker remained on top of Mr Lovegrove while he thrashed around, at which point the support worker who had stayed in the corridor entered the room and took hold of one of Mr Lovegrove’s arms, allowing the other support worker to stand up. Mr Lovegrove was told he could get up but nothing happened. When staff realised he was not breathing they dialled 999, administered CPR and used a defibrillator, but paramedics pronounced him dead at the scene.
HSE’s investigation found the level of supervision and observation given to Mr Lovegrove immediately before his death, and more generally, was inadequate and not in accordance with his care plan. This stated he should have 2:1 observation, meaning he should have two carers positioned within arm’s length and able to see him at all times.
The investigation also found the hospital previously used restraint techniques known as MAPA (Management of Actual or Potential Aggression). But as a result of recommendations by the Healthcare Commission after an inspection at Cedar Vale in February 2006, Castlebeck decided to replace MAPA techniques with a different restraint method provided by a company called Maybo, designed to be more in-keeping with conflict avoidance.
Staff undertaking Maybo training had expressed concerns that the techniques would not be adequate to deal with the risks posed by Mr Lovegrove, so the company visited Cedar Vale and noted Maybo techniques were not being employed and there were inconsistencies in the approach by staff. The company also noted that those who had been trained had not rehearsed or practised their new skills.
The court heard that Mr Lovegrove’s care plan was out of date as it made no reference to Maybo techniques and instead referred to MAPA techniques, which staff had been advised against using. The care plan made no reference to Mr Lovegrove’s tendency to pull staff to the ground and gave no specific guidance as to how such potentially-dangerous situations should be handled. It also failed to focus on the need to monitor Mr Lovegrove’s well-being during restraint and failed to address the circumstances in which, if ever, it was appropriate to decrease Mr Lovegrove’s observations from 2:1 to 1:1.
Nursing staff were not responding to each situation where a holding technique was used on Mr Lovegrove, as required in his care plan. No nursing staff had responded to the incident in the corridor before the incident in his room when he died.
Staff were not adequately trained in first aid and no members of staff were trained in the use of the particular defibrillator available at Cedar Vale on the day Mr Lovegrove died.
Castlebeck Care (Teesdale) Ltd, now in administration and whose registered address is c/o Grant Thornton UK LLP, Hardman Square, Spinningfields, Manchester, was fined £100,000 after being found guilty of breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974.
Section 2(1) of the Health and Safety at Work etc Act 1974 states: “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.”
Section 3(1) of the same Act states: “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.”
After the hearing HSE Principal Inspector Frank Lomas said:
“The failings of Castlebeck Care (Teesdale) Ltd are substantial. They fell far below required standards of care. At the time of this tragic incident the breaches were relatively longstanding and had been the subject of specific warnings, which had not been acted on.
“There was a failure to implement specific recommendations relating to the management of Mr Lovegrove’s behaviour made in a report by Maybo in September 2005, and a failure to implement requirements and recommendations made by the Healthcare Commission following a visit in February 2006.
“The support worker should not have been left alone with Mr Lovegrove. If another member of staff had been observing as required by the care plan, it would have been less likely that events would have unfolded in the way they did. Consequently this would have reduced the risk to Mr Lovegrove and staff.”