Legal News

A care provider has been prosecuted over the death of a mental health patient at a secure hospital in East Bridgford, Nottinghamshire.

Mental health patient Derek Lovegrove, 38, suffered a cardiac arrest while being restrained at Cedar Vale – a 16-bed, nurse-led mental health unit for patients with severe, challenging behaviour.

He died on 10 July, 2006 after staff employed by care provider Castlebeck Care (Teesdale) Ltd used an unauthorised technique to restrain him.

Mr Lovegrove suffered from severe mental impairment and was registered blind. He was also 75% deaf in both ears with poor speech, including limited vocabulary. Mr Lovegrove communicated with staff using the Makaton system of signs and was classed as a high-risk patient because he was prone to aggression – which included the destruction of property, as well as violence towards staff and self-harming.

On Monday and Tuesday (28-29 April), Nottingham Crown Court heard that between June 2005 – when Mr Lovegrove first moved to Cedar Vale from Rampton Hospital – and May 2006, 95 incidents involving Mr Lovegrove were recorded, with restraint being used by staff in 32 cases.

The court was told that that, minutes before his death, Mr Lovegrove had been restrained for a short period of time by three support workers in the corridor, after making a grab for two of them.

After the incident, one support worker took him back to his room, while another of the three support workers stayed in the corridor and one went to the kitchen.

Mr Lovegrove was left in room with one support worker, whom Mr Lovegrove pulled down on top of him. The support worker remained on top of Mr Lovegrove while he thrashed around. The support worker who had stayed in the corridor entered the room and took hold of one of Mr Lovegrove’s arms, allowing the other support worker to stand up.

Mr Lovegrove was told he could get up, but did not. The staff members present realised he was not breathing and dialled 999 before administering CPR and using a defibrillator.

However, paramedics who attended pronounced Mr Lovegrove dead at the scene.

The Health and Safety Executive’s (HSE) investigation found that the level of supervision and observation given to Mr Lovegrove immediately before his death – and more generally – was inadequate and not in accordance with his care plan, which stated he should have 2:1 observation.
This means Mr Lovegrove should have two carers positioned within arms’ length and able to see him at all times.

The HSE investigation also found the hospital previously used restraint techniques known as MAPA (Management of Actual or Potential Aggression) – but after recommendations by the Healthcare Commission following an inspection at Cedar Vale in February 2006, Castlebeck decided to replace MAPA techniques with a restraint method provided by a company called Maybo, which is designed to help avoid conflict.

Staff undertaking Maybo training had expressed concerns that the techniques would not be adequate to deal with the risks posed by Mr Lovegrove, so Maybo experts visited Cedar Vale and noted Maybo techniques were not being employed and there were inconsistencies in the approach by staff – and those who had been trained had not rehearsed or practised their Maybo skills.

Mr Lovegrove’s care plan was also out-of- date and made no reference to Maybo techniques. The care plan also made no reference to Mr Lovegrove’s habit of pulling staff to the ground – and gave no specific guidance as to how such situations should be handled.

Mr Lovegrove’s care plan also failed to focus on the need to monitor Mr Lovegrove’s wellbeing during restraint – and failed to address the circumstances in which it might be appropriate for just one member of staff to be alone with him. Furthermore, staff were not adequately trained in first aid – and no staff members were trained to use the particular defibrillator available at Cedar Vale on the day Mr Lovegrove died.

At Nottingham Crown Court on Tuesday, Castlebeck Care (Teesdale) Ltd was fined £100,000, after being found guilty of breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974.

The company is now in administration.

Duncan Lewis Mental Health Solicitors

Duncan Lewis Mental Health Solicitors regularly visit hospitals and prisons and can advise on issues such as detention under the Mental Health Act 1983, access to mental health services – and treatment reviews for mental health patients.

Duncan Lewis is a leading firm of Legal Aid Solicitors and in some cases may be able to advise the next of kin or carer of a mental health patient.

For expert advice on mental health law, contact the Duncan Lewis Mental Health Solicitors Helpline on 0203 114 1124.