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...
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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.