Care firm fined after death of patient held by untrained staff

Anthony Pinder, 42, who had a learning disability and could be violent, was held face down for around 90 minutes by four staff at the Old Vicarage nursing home in Stallingborough, near Grimsby, in October 2004.

Staff, fearing a violent outburst, held him on the floor of a courtyard, with one person holding his legs and another straddling his back, Leeds Crown Court heard yesterday. At one stage, his arm was tied behind his back with his jumper.

Pathologists said the restraint used made a "significant contribution to his death," although the precise cause could not be determined.

The court heard that Health and Care Services (UK) limited, part of the Craegmoor group, failed to ensure staff were trained in safe restraint techniques.

Paul Greaney QC, prosecuting, said it was "an extraordinarily long and dangerous period for a restraint to take place over" but such poor techniques were not the fault of the staff who were "simply doing their best in a difficult situation, acting without training and therefore on instinct."

Five months before Mr Pinder's death, the Commission for Social Care Inspectorate highlighted an urgent need for restraint training but still none was given.

The company's failure was a breach of the Health and Safety at Work Act, an offence which the firm admitted at an earlier court hearing.

Stephen Lineham QC, for the company, said the business was a "different creature" six years on. It was under a new owner and had a new management team which invested in staff training.

He said a senior manager had "parted company" with the business following the tragedy.

Following the case, Mr Pinder's family said: "It has been six years since Anthony had his life cruelly and abruptly ended at the Old Vicarage nursing home, but he is constantly in our thoughts and will remain so.

"Anthony was a vulnerable adult with a range of behavioural problems that had been with him since birth. He needed specialist care, yet he died after being restrained in a dangerous manner for a very long period of time, and I don't think we'll ever fully come to terms with why that was so.

"The failings that came to light during the prosecution are deeply shocking, and the blame in our eyes lies firmly at the door of senior management who failed to provide training in safe restraint techniques for the staff at the home. We have no grievance with the duty staff directly involved, who were doing their best in extremely testing circumstances, and who frankly didn't know any better."

The family said they felt "badly let down" by a company which are "supposed to be a market leader".

"We take some comfort from their admission of guilt and reassurances that lessons have been learned. Today's sentencing also sends a clear message to other care home operators of the need to train staff fully, professionally and for all eventualities.

"Sadly this has all come too late for us, but we hope it helps others so that nobody else has to endure the same pain and heartache as us."

Health and Safety Inspector Brian Fotheringham described Mr Pinder's death as "entirely avoidable", adding: "Senior management knew that staff at the Old Vicarage often had to physically intervene and restrain residents, but they failed to ensure that staff were trained in appropriate and safe techniques."