NEWS COURTS cutions from the HSE.
CARE HOME OPERATOR SENTENCED AFTER DEATH OF
VULNERABLE PATIENT A care home operator has been fined after the death of a vulnerable patient in one of its residences in Owestry, Shropshire.
Shrewsbury Crown Court heard how, on 15th February 2015, Michael Ibbetson, a resident of a care home operated by Akari Care Ltd was found at the bottom of a flight of stairs leading to the cellar with his wheelchair on top of him. Mr Ibbetson, who had one leg amputated at the knee, was able to operate his wheelchair alone and had days of confusion. He was last seen by the nurse on shift going into a lift by the
COMPANY FINED £1.1M FOLLOWING
RED ARROWS DEATH An ejection seat manufacturer has been sentenced following the death of a Red Arrows pilot in 2011.
Lincoln Crown Court heard that Martin Baker Aircraft Company Ltd made and supplied the ejection seat that failed on 8 November 2011 after Flt Lt Sean Cunningham, a pilot, was ejected whilst the Red Arrows were preparing to take off from RAF Scampton, Lincolnshire.
An investigation by the Health and Safety Executive (HSE) found that a mechanical fault led to the failure of the parachute deployment mechanism designed to bring the 35-year-old pilot to ground safely. This resulted in the main parachute failing to deploy.
Flt Lt Cunningham suffered multiple serious injuries and was pronounced dead shortly after being airlifted to hospital.
A number of inquiries took place after the incident, including a
twitter.com/TomorrowsHS
cellar door to go to his room on the first floor.
The HSE found that although the door to the cellar had a key pad latch and was fitted with a self-closing device, it opened onto the stairs so that the first step was directly behind the door. The handrail was fitted in such a way that it was not possible to have a good handhold along its length, and there was no hand rail at the top of the stairs due to the door opening.
The door was used daily by kitchen staff and the maintenance man. The investigation also found that Akari Care Ltd’s had not produced a risk assessment for access and use of the cellar and therefore did not take account of the fact that the door opened inwards directly onto the stairs without a sufficient landing area.
police investigation, a Ministry of Defence investigation and an Inquest. HSE worked alongside Lincolnshire Police, the Coroner, and the military investigators throughout these inquiries.
HSE inspectors found that in the 1990s two aircraft manufacturers had made Martin Baker Aircraft Company Ltd aware of issues with the drogue and scissor shackles, designed to deploy the main parachute for the ejection seat mechanism. The design of the component was such that at zero speed and zero altitude the ejection seat could fail to operate as intended.
Martin Baker Aircraft Company Ltd of Lower Road, Higher Denham, Near Uxbridge, Middlesex pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work Act. The company has been fined £1.1 million and ordered to pay costs of £550,000.
HSE Operations Manager Harvey Wild said: “Our investigation found that Martin Baker Aircraft
Akari Care Limited of Albion Street, Leeds, was found guilty of breaching Sections 2(1) and 3(1) of the Health and Safety at Work Act 1974 and has been fined £120,000 and ordered to pay costs of £41,997.48.
Speaking after the hearing, HSE inspector Stephen Shaw said: “This tragic incident could have been avoided.
“It is unlikely Mr Ibbetson would have known the key pad number to the door, therefore the door cannot have been properly closed and locked.
Stephen continued: “In this case, the risk assessment should have identified the potential risks to both Akari Care employees, visitors and residents of a door which opened inward without sufficient landing.”
Company Ltd failed to take all reasonably practicable steps to protect users from the risk of harm after it was told of concerns regarding the shackles which deployed the main parachute.
“The death of Sean Cunningham was therefore avoidable. Our thoughts today are with his family, who are both devastated by these appalling events and proud of Sean for fulfilling his ambition of becoming a pilot with the Red Arrows,” he continued.
11
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56
