The Cost of Mistakes


I have a draft post written about making mistakes but while I was compiling, I remembered this story about Jesse Moores and on the scales of mistakes it has a much more important and tragic consequence.

Jesse Moores was a resident at The Chines Home in Enfield, London. He had autism and Tourette’s syndrome and required 24 hour care. That care was to be provided at The Chines, a home run by Robinia Care and unfortunately, Jesse Moores choked to death in 2005 while under the care of Robinia Care Group.

Enfield Council took the company to court and according to the article in Community Care, the home itself closed in 2006 after a scathing report in 2005 found that there were a stream of requirements that the home needed to meet in order. Basically it was a sub-standard service at a sub-standard home and poor practice has been seen to lead directly to the death of a resident.

The sentences were delivered yesterday after the verdicts had been decided (namely that the company and the deputy manager were guilty).

The home’s deputy manager at the time, Patience Etchu-Abangma, who was on duty at the time of the death, was fined £1200.

The London Paper details some of Etchu-Abangma’s actions that day

Etchu-Abangma is accused of:

failing to make sure everyone was aware of the risk of Mr Moores obtaining food and choking on it;

telling the care workers to call her if something happened instead of calling 999;

failing to leave an instructions about what to do in an emergency; failing to give any suitable instructions when Ms Ojobar (agency member of staff) phoned her to tell her there was a problem with Mr Moores;

directing her to do nothing and saying she would call an ambulance herself;

delaying calling an ambulance for at least 15 minutes after receiving the phone call;

untruthfully telling the emergency services on the phone that efforts were being made to resuscitate Mr Moores;

failing to take any action when she returned to the care home even though Mr Moores was unconscious and not breathing.

It is all really pretty damning under any circumstance. Apart from the individual though, it is hard to believe that a management structure can exist where these issues remain hidden. I expect that is why the company itself has been found culpable as well as the individual.

Robinia Care or whatever they are called now, were, indeed,  fined £250 000 for the breaches in health and safety legislation which led to Mr Moores’ death.

The Robinia Care of 2005 has been through different hands since these occurrences including Bridgepoint – an international ‘private equity group’ who owned them at the time of the incident – clearly a company with its heart set on providing a good quality residential care service – although to be fair, they were already planning to sell it at the time – for a cool £80 million. I wonder how much money they were paying in wages to ensure they had a high quality of care staff.

I wonder how long profits can be squeezed out of the caring sector into private companies that have little interest save the in the profits that can be generated by putting in place poorly paid and inexperienced and possibly incompetent care staff.

Robina pseudoacacia bloom April 22, 2003 Hemin...
Image via Wikipedia

At least I hope to see more of these types of fines when there is proven culpability. It should not be easy for companies that make massive profits to wash their hands of their responsibilities – and for that reason, I welcome the verdicts in this case.

6 thoughts on “The Cost of Mistakes

  1. That is very, very disturbing. Will the manager have to spend any time in jail? Also, the fines seem rather paltry given the severity of what happened.

  2. So true.. and no, there is no jail sentence because it is a civil rather than criminal action (I understand) so it is a fine rather than a prison sentence..

  3. At least all of this stuff is coming to the fore now -for a long time it has just been ignored. There was another case yesterday of patients who had been overdosed on diamorphine at Gosford Memorial Hospital, and it made it to the top of the news bulletin, though the Beeb did a strange thing with it; they put the story first on its trailer that they do during the title sequence and then reported it third. I think there’s a struggle going on in the editorial dept..

  4. Dear cb

    My apologies for not being able to address you by your full name.

    I am Jesse’s father and a few moments ago I came across your article “The cost of Mistakes”

    Following the court case in February and the sentencing on Monday I wanted to ensure that this case received as much exposure in the press as possible. I felt that it was extremely important that a strong message went out to anyone either running a care home or working in a care home that if they fail in their duty of care towards any resident they will be held accountable as was the case here.

    Robinia Care Group are now a better company, however, it took them at least 19 months following Jesse’s death and ultimately a new Chief Executive to learn from their mistakes. I was deeply offended by the comment made by Mr Glen von Malachowski (Robinia’s previous Chief Executive) regarding the care industry (published by The Daily Mail 20th April) which I felt was an insult to all of the dedicated people who do such a good job in this often demanding environment.

    Regarding Patience Etchu Abangma I have nothing more to add to your comments and I am confident that your readers will reach their own conclusions.

    Whilst the BBC covered this story well, as will the local press, I was very disappointed that the sum total of coverage in the National press today was two column inches in The Daily Telegraph!.Is this is an indication of how un-newsworthy stories relating to the disabled are considered?

    In view of this I was delighted to read The cost of Mistakes and I wanted to thank you for your thoughtful and sympathetic words – they mean a great deal to both my family and myself.

    With kind regards

    Bob Moores

    • Bob,
      Thanks for your words and for taking the time to comment. I completely agree about the coverage. I find it unbelievable that it has passed so much of the media by.
      I saw the article in the Daily Mail and actually chose not to link to it. I couldn’t believe it nor the callousness it indicated.
      I hope it does send a strong message because regardless of the lack of appropriate coverage, I expect that the corporate lawyers will, at least, be more aware of their responsibilities.
      And I wish you and your family all the very best.

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