Northern Ireland care home company fined after ‘dreadful and tragic’ death of 'highly thought of' 85-year-old resident

District Judge Rosie Watters said while it appeared the company “has dealt with this appropriately,” the death of the resident “would appear avoidable”.

Imposing the fine on Healthcare Ireland (No. 2) Ltd, the district judge added: “Or at least avoidable in the sense that, that there would have been someone there to assist after the fall had the home complied with the care plan.”

The defendant company, with an address at St. Helen’s Business Park in Holywood, entered a guilty plea at Lisburn Magistrates Court to failing to ensure, as far as reasonably practicable, the health and safety of non-employees, on September 14, 2024.

Opening the facts of the case, a prosecuting lawyer outlined that Mr William Moore, known by everyone as Billy, was a resident in Wallace House, part of the Pond Park Care Home at Derriaghy Way, Lisburn.

Due to his dementia, Billy had been moved to Wallace House but the court heard that after 8am that morning, staff found him in his room, lying on the floor in a large pool of blood.

He had sustained “a significant head injury”, said the lawyer, adding that when staff checked for signs of life, “unfortunately no response was detected.”

The tragic incident triggered an investigation by the Health and Safety Executive for Northern Ireland (HSENI) who found a number of failings in Mr Moore’s care plan and how it was implemented.

The court heard that when Mr Moore was in the unsecured, main part of the home, he was set for half hourly checks as he was at risk of absconding.

When he was moved to the dementia unit, those 30-minute checks remained in place and in addition, there was to be a pressure buzzer mat placed in his room so that if he got out of bed, staff would be alerted.

The court heard the HSENI investigation found that, in addition to the absence of a pressure buzzer mat, staff had not conducted the half hour checks as set out in Mr Moore’s care plan, even though two members of staff claimed they had.

The investigation also found that internal audits of the care plan had failed to identify shortcomings.

When she was interviewed under caution, Carol Cousins, strategic director for Healthcare Ireland (No. 2) Ltd, accepted that if the plan had been followed and a buzzer mat was in place, Mr Moore “may have received help earlier than was the case”.

She told investigators that Mr Moore, who had been a resident for two years, “was highly thought of by all members of staff, and his death and its circumstances are deeply regretted by everyone at the home.”

Lodging a plea in mitigation, defence KC Frank O’Donoghue quoted from Ms Cousins’ statement where she outlined that “the company, its directors and employees, can appreciate the devastating impact that this has had on his family”.

The senior brrister said: “The company unreservedly apologises to his family for the shortcomings in his night time supervision that occurred, and which, had they not occurred, may have resulted in Billy receiving help earlier than was the case.”

Urging District Judge Watters to accept that “this is a very full and unreserved acknowledgement of shortcomings,” he submitted that it was also “an expression of deep regret in the family, which the company reiterates this morning, in court, and in this public setting”.

Mr O’Donoghue explained that Healthcare Ireland (No. 2) Ltd “is a small operation”, encompassing three nursing facilities and although it has a turnover just over £2.5 million, the annual profit is around £100,000.

He revealed that since the incident in September 2024, two members of staff have been dismissed and referred to the Nursing and Midwifery Council, others have been given extra training and steps have been put in place to ensure there is no repetition of such an incident.

"This is otherwise a well-run operation,” said Mr O’Donoghue, “but everything which I have said is entirely secondary to the suffering of Mr Moore’s family.”

Describing it as a “dreadful and tragic incident which must have been very distressing for the family,” District Judge Watters imposed the £10,000 fine and allowed the company 28 days to pay.

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In a statement, the HSENI said: "Healthcare Ireland (no.2) Limited pled guilty to an offence under Article 5 of the Health and Safety at Work (Northern Ireland) Order 1978.

"The investigation found shortcomings in the residents’ night-time supervision. It was established that they had not been observed by staff since 6.45am that morning, contrary to the requirements of their individual care plan. Furthermore, the resident who was assessed as having a high risk of falls required the placement of a buzzer mat within his room. This was to alert staff should he step onto the mat, wander, or fall. At the time of the incident no buzzer mat was present within the room.

"The investigation revealed inconsistent knowledge amongst staff as to the requirement for the mat, and the absence of the mat was also not identified as part of the Home’s management auditing process

“Prosecutors in the PPS’s Fraud and Departmental Section worked closely with the Health and Safety Executive for Northern Ireland to build a robust prosecution case”.

HSENI Major Investigation Team Inspector Kiara Blackburn explained: “Individual care plans for nursing home residents must be followed. The requirements within these plans should be clearly understood, effectively implemented, and consistently maintained through appropriate staff monitoring.

“Assistive technologies, such as sensor pressure mats used to detect patient movement, require careful oversight and regular maintenance to ensure they function correctly and support the safety and wellbeing of service users.”