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Care home operator fined following death of resident

1 November 2013

A healthcare firm has been fined for safety failings after a resident suffering from dementia fell to his death from a first floor window of an Essex nursing home.

Kenneth Terrey, 74, of Buckhurst Hill, Essex, had been a resident at the Paternoster House Care House in Epping Forest for less than three months when he died on 9 March 2011.

The owners of the nursing home, Barchester Healthcare Homes Limited, were sentenced today (1st November) after an investigation by the Health and Safety Executive (HSE) established that his death could have been prevented had a faulty window restrictor been checked and fixed.

Chelmsford Crown Court heard that Mr Terrey became a resident at the nursing home on 23 December 2011 and had a room within the dementia unit, known as “Memory Lane”.

On 6 March 2011 he had tried on a couple of occasions to leave the unit, which was located on the first floor, before he was seen making his way back to his room.

Minutes later a visitor outside the home noticed a first floor window was fully open. Mr Terrey was seen to climb out of the window, but as he did so he fell to the ground landing in some bushes.

He died three days later as a result of his injuries.

The HSE investigation found that at the time of the incident, the window restrictor that should have prevented it from opening fully was not working. Guidance has been in place since 1989 stating that windows in facilities where there are vulnerable patients should be restricted to a maximum opening of just ten centimetres to prevent falls. Staff had also not been properly trained in how to carry out proper window safety checks and there was no window management safety system in place.

Barchester Healthcare Limited, of The Chambers, Chelsea Harbour, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974. The company was fined £175,000 and ordered to pay costs of £22,961.

Speaking after the hearing HSE Inspector Corinne Godfrey, said:

“Mr Terrey’s death was a wholly preventable tragedy caused by unacceptable management failings on the part of Barchester Healthcare Limited. They put him at unnecessary risk.

“Working in a care home is a specialised job, which involves dealing with vulnerable people. Care homes must ensure that they have the correct training in place for all their employees, and that they work to adequately assess and eliminate all possible risks.

“Falls from windows is a particularly important issue in the healthcare sector and every year vulnerable people are killed or severely injured in such incidents.

“Any windows that are accessible to vulnerable people should be restrained so that they cannot be opened enough to allow people to fall out.”

Mr Terrey’s widow Ann added:

“I put my faith and trust in Barchester Healthcare Homes– after being assured by them that Ken would be safe and well cared for.

“This proved not to be the case, as he was allowed to fall out of a window and land in bushes 20 feet below. This fall led to his premature death.

“On investigation, it was found that Barchester had failed to maintain the windows adequately. It is because of them that I have lost my beloved husband.

“I hold Barchester 100% responsible for Ken’s death and action must be taken to ensure that such an avoidable tragedy does not happen again. This care home group, and others like them, need to be made aware that people like my Ken are precious and loved by their families and friends, and to ensure they exercise responsibility for their safety and welfare.”

Notes to Editors

  1. The Health and Safety Executive is Britain’s national regulator for workplace health and safety. It aims to reduce work-related 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. Further HSE news releases are available at


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