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Basildon Hospital admits to safety failings

Kyle Flack died after trapping his head in bed railings

Posted on 01 March 2010

Kyle Flack, a quadriplegic and young man with profound learning difficulties, died at Basildon Hospital in October 2006 from asphyxiation when his head became trapped in the bed railings of his metal bed.  The inquest into Kyle’s death resulted in a damning verdict which listed many failings at the troubled hospital which has since faced accusations of poor standards of care and hygiene following an unannounced inspection by the Care Quality Commission.

Health and Safety Executive

Following Kyle’s death the Health and Safety Executive (HSE) became involved in his case.  Basildon and Thurrock University Hospitals NHS foundation trust has now pleaded guilty to a criminal charge involving lapses in safety procedures in its care of Kyle. The HSE prosecuted the trust at Basildon magistrates court under the Health and Safety at Work Act for not ensuring a patient's safety. The magistrate, Elizabeth Hunter, said the offence was so serious that she was referring the trust for sentencing at Basildon crown court on 15th March where a judge would be able to impose an unlimited fine.

Kyle’s story

Kyle was blind, deaf, born with cerebral palsy brain damage and a quadriplegic. Whilst he had no language he was able to communicate by making different noises to express feelings including happiness and pain.  Kyle was admitted to Basildon Hospital in October 2006 after becoming ill.  Despite requests from Kyle’s mother the bed he was in was not fitted with the appropriate safety bumpers.  When Kyle was transferred to a new ward staff were not aware that he was deaf, and one-to-one nursing care was removed.  His bed was still not equipped properly for someone with his needs.  Two days after being admitted to hospital Kyle died after being found with his head caught in the cot sides.

Inquest verdict into Kyle's death

The jury gave their verdict on the afternoon of Monday 20 July 2009 finding that the circumstances leading to the death were:

  • Inadequate risk assessments and reassessment of Kyle;
  • The level of supervision had been inadequate for Kyle’s complex needs;
  • There had been poor record keeping on behalf of the Trust;
  •  Ineffective cascading of information which failed to support staff at grass roots level;
  •  There had been insufficient training on the proper use of cot sides and bumpers;
  •  There had been a failure to easily access the previous incident report form;
  •  The cause of death was contributed to by neglect.


Leigh Day and healthcare services

Frances Swaine, partner and head of the human rights department at Leigh Day, was approached by Mrs Flack to represent her at the inquest into Kyle’s death.  Frances has been heavily involved with cases involving poor levels of health and other services that are offered to people with learning difficulties, and has advised Mencap on this topic following the publication of their report, Death by indifference.  She is currently representing a number of families whose loved ones have died at Basildon and Staffordshire Hospitals. 

Frances welcomes the news that Basildon Hospital has admitted failings in its care of a vulnerable young man whose death could easily have been prevented.  She said:

“The threat of an unlimited fine that the crown court can impose for health and safety breaches should prompt Basildon Hospital to reassess its policies relating to the care of patients with severe learning difficulties.  Kyle died alone, in pain and fear.  His death could easily have been avoided and his family now hope that the publicity raised by his death will draw attention to the care of disabled people throughout the UK.”

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