Health and Safety Executive
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Shropshire health trust fined over patient death

An 89-year-old man died after hospital staff left him with only one rail on his bed to prevent him from falling out.

Pensioner Francis Steele, of Lower Netchwood, Dilton Priors, near Bridgnorth, died two weeks after falling from his bed at Telford’s Princess Royal Hospital on 21 November 2007.

Shrewsbury & Telford Hospital NHS Trust was yesterday fined £50,000 after admitting to health and safety breaches which led to the incident.

The Health and Safety Executive (HSE) prosecuted the Trust after an investigation found the hospital had failed to provide Mr Steele with a bed rail that would have prevented the fall.

Shrewsbury Crown Court heard how a senior nurse decided that Mr Steele, described as very frail, needed bed rails but staff could only find one. Nobody made any further attempts to find another rail and the following day the elderly man was fatally injured when he fell from the open side of the bed.

The court was told that hospital staff did not know where to find the rails as there was no system of storage and heard evidence that staff were unable to look for another rail later in the shift as the ward was grossly understaffed.

Shrewsbury & Telford Hospital NHS Trust, of Mytton Oak Road, Shrewsbury, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974. In addition to the fine it was ordered to pay £8,476 costs.

HSE investigating inspector Mr Lindsay Hope said:

"Shrewsbury & Telford Hospital NHS Trust’s failure to provide a bed rail for a frail, vulnerable patient who urgently needed it is unacceptable.

"The failure was compounded by chronic staff shortages. Just a few weeks before this incident, one nurse was so concerned by staffing levels in the ward she had written to the trust board, but no action was taken.

"The trust’s own policy was not to trigger any action on staff shortages until the levels became ‘high risk’. As a result, the trust was typically working at high risk or very high risk.

"It is a tragedy for Mr Steele and his family that Shrewsbury & Telford Hospital NHS Trust failed in its duty of care towards him."

Notes to editors

  1. The Health and Safety Executive (HSE) is Britain's national regulator for workplace health and safety. It aims to reduce death, injury and ill health. It does so through research, information and advice, promoting training, new or revised regulations and codes of practice, and working with local authority partners by inspection, investigation and enforcement.
  2. Section 3(1) of the Health and Safety at Work etc. Act 1974 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."
  3. Visit for further HSE press notices.

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Issued on behalf of the Health and Safety Executive by COI News & PR (West Midlands)

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