The CQC has updated their guidance on window safety following a deliberate attempt by a care home resident to defeat a window restrictor which led to their tragic death.
Earlier this summer, Abdul Khan, an Associate Lawyer in the Keoghs Crime & Regulatory team appeared at the inquest on behalf of the care home, alongside Julie Kendrick of Crown Office Chambers. [1]
The Inquest concerned the tragic death of an elderly resident at a care home. The resident suffered from confusion and memory loss following a recent stroke. He had absconded from previous care homes on a number of occasions via a fire exit. In order to ensure his safety, and in association with local social services, the resident was moved to the care home in question as it was considered reasonably secure.
The resident lived in a first-floor room, with all fire doors and exits locked via key codes. The windows were secured with window restrictors that complied with the relevant British Standard BS EN 14351-1 and BS EN 13126-5. These standards specify that window restrictors should be effective to withstand a static force of 350 newtons for 60 seconds and restrict the window from opening more than 100mm.
During the course of proceedings, evidence was heard that the window restrictors had been properly fitted and maintained by the care home. Documentary evidence of record keeping completed by competent maintenance just two days prior to the incident, were also presented to the Court.
During the early hours of a December morning in 2020, the resident was able to overcome the window restrictor by applying sufficient force to detach the fixing which secured the window restrictor to the window frame. He was able to do so without the use of tools or assistance. The resident exited the window and sadly fell to his death.
Following conclusion of the Inquest, the Coroner was sufficiently concerned to issue a Prevention of Future Deaths (PFD) report addressed to The Secretary of state for Health and Social Care, (DHSC) The Chief Executive of the Care Quality Commission (CQC) and The Chief Executive of the British Standards Institute, (BSI). [2]
The matters of concern related to the guidance provided to operators of residential care homes in respect of window restrictors and the standard that they are required to meet. The current guidance provided to care homes does not deal with deliberate attempts to defeat a window restrictor, as heard during this Inquest. Evidence was heard that in 2019, the Health and Safety Executive (HSE) published a Research Report (RR115) Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in a health and social care setting:
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N.”
This research was not made available to operators of residential care homes or manufacturers/suppliers of window restrictors by the CQC or the DHSC.
Following HM Coroner’s PFD Report addressed to the DHSC, the Right Honourable Stephen Kinnock MP confirms discussing the case with the CQC. In response, the CQC have now updated their ‘Learning From Safety Incidents’ webpage, which highlights that the British Standard for window restrictors does not factor in deliberate attempts to defeat a restrictor using impact forces. [3]
In response to the concerns raised by the Coroner, the BSI are proposing to amend the British Standard, to include a requirement for both; restricting the device to a maximum opening gap of 89mm and for the window to resist an application load of 850 newtons. The BSI have also proposed to introduce amendments to the national product standard for both glazing and steel-framed windows to support the 850 newtons point load.
The CQC have signposted providers to source material noting that the previous guidance of a static load of 350 newtons may not be sufficient to prevent determined patients to force the window. [4]
It is expected that the CQC will also signpost operators of care homes to the BSI’s proposed amendments to the standard, once these are formally agreed and published.
The implications for residential care home operators are potentially significant. Although the BSI proposals will require implementation through the usual development process, it is anticipated that these proposals will be accepted.
Operators of care homes up and down the country should be particularly mindful of the updated CQC guidance which can be found on their website. As has always been the case, registered providers must manage the risk of falls to residents and assess those risks. That includes looking at any risks arising from the premises, and for individual residents at risk, assessing what further action may be needed to prevent them falling from a height.
With this in mind and with the overarching principle of ‘person centred care,’ the sector will need to continue to be vigilant in addressing how to manage and indeed reduce the risk of resident’s absconding. Questions will inevitably include the suitability of already installed window restrictors, as well as physicality, escape history and relocation.
Both the CQC and DHSC are fully aware of the implications, as succinctly outlined by HM Coroner in his PFD. It is though crucial that an already embattled sector is provided with support in effecting preventative measures designed to avoid such tragic events from happening again.
Our specialist health and social care regulatory team at Keoghs LLP will continue to monitor developments and provide assistance. Should you have any questions in relation to this article or what these proposals mean for your business, please do not hesitate to get in touch.
For more information, please contact Abdul Khan - Associate
[1] Julia Kendrick - Crown Office Chambers
[2] Terrence Taylor: Prevention of future deaths report - Courts and Tribunals Judiciary
[3] NHS England » Health Building Note 00-10: Design for flooring, walls, ceilings, sanitary ware and windows
[4] NHS England » Health Building Note 00-10: Design for flooring, walls, ceilings, sanitary ware and windows
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