Surrey firm fined over death of 93-year-old following burns at Bracknell care home

A former care home manager has avoided prison following the death of a dementia patient after she was put into a scalding bath.

Frances Norris, 93, died on February 8 2015, three days after she was put into the bath by carer Noel Maida, 50, and a junior carer at Birdsgrove Nursing Home in Bracknell, Berkshire, owned by Aster Healthcare.

After she had been put into the bath, Ms Norris said it was "cold", prompting Maida to tell the junior carer to add more hot water, the Royal Courts of Justice in London heard.

Ms Norris was in the bath for "several" minutes before the junior carer noticed the temperature was too high and she was taken out, a three-day sentencing hearing was told.

Ms Norris was taken to hospital before being transferred to the specialist burns unit at Chelsea and Westminster Hospital, where she later died. The court heard 12% of Ms Norris's body was covered in serious burns.

Aster Healthcare, based in Surrey, was ordered to pay a fine of £1.04 million within three years after admitting corporate manslaughter over Ms Norris's death.

Elisabeth West, 46, was the care home manager at the time and was "well aware" of problems that had been raised for a number of years in regards to the hot water systems at the home, the court was told.

As she handed West a nine-month sentence, suspended for 18 months, Mrs Justice Thornton said the former care home manager was "unqualified" for her position and was "out of her depth".

She said of Ms West: "She was unsupported and bullied. She had no training and was unprepared for the challenge. She knew enough about the risks of hot water and the long-standing problems at the home. She was a nurse and was well aware of the risks of scalding.

"It is not credible to suggest she had no real knowledge of the TMVs (thermostatic mixing valves) and safety issues. The fact the water was scalding was apparent to anyone who worked at the home."

Maida was sentenced to 16 weeks, suspended for 18 months, after he pleaded guilty on Wednesday to a failure to discharge a duty.

West had also pleaded guilty to the same charge. Aster Healthcare pleaded guilty to corporate manslaughter.

The company admitted falsifying water temperature records, falsifying a record of the servicing of the thermostatic mixing valves, and falsifying a contract of the servicing to be provided to the Care Quality Commission and Health and Safety Executive.

Aster Healthcare under director Sheth Jeebun was run under a management style that was "chaotic" and "demanding", Mrs Justice Thornton said.

As well as being fined £1.04 million, Aster Healthcare must pay prosecution costs of £184,513.13 within two weeks.

Mrs Justice Thornton said: "Mr Jeebun delayed expenditure until he had to because regulators were breathing down his neck, and not when staff raised issues."

The judge said Aster Healthcare was a company that had used "cost cutting" and had "fallen short of standards".

She added that after Ms Norris's death "attempts were made to mislead" the investigation.

"False records were created and minutes of meetings were rewritten after they had been destroyed," she said.

The company was also ordered to take out a full-page advertisement in two health and nursing magazines and include details of its conviction on its website for two months.

Birdsgrove Nursing Home was closed in 2016 following the death of Ms Norris.

Mrs Justice Thornton told the court that "no punishment can ever compensate the family for their loss in the circumstances in which Ms Norris met her death".

Following the sentencing, Ms Norris's family released a statement that said: "Mum will always be someone special to us, a woman who lived through the Second World War, who left school at 14 to support her own mother in caring for her eight brothers and three sisters.

"Mum was warm, generous and kind-hearted. She was always an independent person, happy with the simple things in life, never wanting much. She was stoical and just got on with things.

"She never complained, even when ill, which was not very often. Sadly, dementia slowly robbed her of her independence until in the later stages of her life she became fully reliant on people to care for her. That trust was shattered when she died at the hands of the care staff at Birdsgrove Nursing Home, who were there to look after her and keep her safe.

"After six and a half years we have finally got some justice for Mum, although it will never compensate for our loss.

"Mum was always a private person, never wanting people to know her business, and we would like to keep it that way out of respect for her."

Detective Inspector Sally Spencer of Thames Valley Police's Major Crime Unit said: "This has been an extremely lengthy and challenging investigation, supported by the Health and Safety Executive providing valuable assistance in ascertaining the facts.

"I would like to thank the family of Frances Norris for their patience whilst this has been carried out.

"Mrs Norris was a vulnerable lady who relied upon others to help her with every aspect of her daily routine. She should never have been placed at such risk of receiving these scald injuries leading to her death.

"The level of care she received before and immediately after being injured was not acceptable. Mrs Norris and her family deserved more from the people and company assigned with providing that level of care.

"Aster Healthcare Ltd, Elisabeth West and Noel Maida were all responsible for providing a care service for Mrs Norris and were themselves experienced within the care industry. The simplest of tasks caused a fatality that, if all of them had taken appropriate steps, could have been avoided.

"I am pleased that the defendants pleaded guilty before the trial. This has at least saved Mrs Norris's family from (the) further stress and anxiety that would inevitably have caused. I hope that today they finally begin to have some closure from this tragedy."

Specialist Prosecutor Eran Cutliffe of the CPS paid tribute to Ms Norris's family and said: "I hope that they can take some comfort from the guilty pleas, sentences imposed, and the fact that those responsible for her tragic death have been held accountable for their gross negligence and failures.

"The prosecution was able to present a compelling case, having identified systemic failings on the part of the senior management of Aster Healthcare Ltd in relation to their approach to health and safety and staff training.

"The company chose to ignore repeated problems and warnings with their hot water system, with the consequence being that Mrs Norris suffered extensive burns whilst being bathed.

"It was this gross breach in their duty of care that caused the untimely and avoidable death of Mrs Norris."