Kevin McNally, who had Down’s syndrome, epilepsy, dementia and a severe learning disability, died after the incident at a nursing home in Smithies Moor Lane, Birstall, in April last year.
The 62-year-old resident, who had lived in the home since 2012, was taken for a shower by two care workers using a shower commode chair.
With Mr McNally loosely strapped in, the chair fell forwards and the impact broke his neck. Staff attempted to resuscitate him but he was pronounced dead in hospital.
Leeds-based St Anne’s Community Services, which was the registered provider at the home, was deemed to have failed in its duty to provide safe care and treatment at Bradford Magistrates’ Court today and fined £190,000.
Jenny Ashworth, prosecuting, told the court that the accident was avoidable as the risk of people sustaining injuries because safety or posture belts were not used or adjusted properly was well known.
In 2008 and again nine days before the accident, the Medicines and Healthcare Products Regulatory Agency issued safety alerts intended to raise awareness of the dangers but St Anne’s Community Services failed to ensure the alerts were brought to the attention of care and nursing staff.
The provider was fined £190,000 for failing in its duty to provide safe care and treatment under the Health and Social Care Act 2008 Regulations and ordered to pay £16,000 towards the cost of the prosecution and a £120 victim surcharge.
Debbie Westhead, deputy chief inspector of adult social care at watchdog the Care Quality Commission (CQC), said: “St Anne’s Community Services failed in its duty to ensure that care and treatment was provided in a safe way, and as a result Kevin McNally died. It is a tragedy which need not have happened.
“When serious incidents occur, we now have additional powers to hold providers to account in the courts. In future if we find that a care provider has put people in its care at risk of harm, we will always consider using those powers to the full to prosecute those who are responsible.”
Following the case, the head of St Anne’s Community Services said they “fully accepted” the outcome.
Chief executive Derek Bray said: “We have been deeply saddened by the events leading to this prosecution and have assisted the CQC throughout its investigations.
“We fully accept the outcome, and have taken our responsibilities in relation to the provision of care for vulnerable people very seriously indeed.”
He added that since the time of the incident, the CQC has carried out checks on St Anne’s Smithies Moor Lane and rated the services as ‘good’, with no concerns.
Mr Bray said they were “absolutely committed to providing the highest level of care to clients” and this was reflected in the positive testimonials presented to the court.