HSE Safety Notice – Vertical lifting platforms or lifts for people with impaired mobility – potential falls from height risks to employees and members of the public from over-riding door locking safety devices

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HSE Safety Notice – Vertical lifting platforms or lifts for people with impaired mobility – potential falls from height risks to employees and members of the public from over-riding door locking safety devices

Key Issues

  • Potential danger from inappropriate use of emergency over-ride devices at the doors of lifting platforms intended for use by people with impaired mobility.
  • Potential for access to be gained to lift well (shaft) when lifting platform/ lift car is at different level.
  • Action required to ensure safe procedures are in place to prevent misuse of landing door unlocking keys except in an emergency situation where access to the lift well is required.

Target Audience

  • Health and social care providers
  • NHS Trusts / Boards
  • Hospitals
  • Public buildings
  • Schools
  • Care homes
  • Catering and Hospitality
  • Education
  • Entertainment and Leisure
  • Retail
  • Services
  • Transport

Introduction:

This Safety Notice is aimed at organisations with vertical lifting platforms for people with impaired mobility, or passenger lifts, installed at their premises.

The Safety Notice informs organisations of the risks from over-riding safety devices at landing doors designed to prevent access to lifting platform / lift wells or shafts.

Safety devices are designed to prevent doors from opening when the lifting platform / lift car is not at the correct position at a landing. Opening the doors when the platform / car is not at the landing presents a significant risk of falling from height.

Background:

HSE is aware of two incidents where emergency landing door keys have been used to override the safety devices designed to prevent opening of landing doors when the platform / lift car is not at the correct landing.

Vertical lifting platforms, like traditional passenger lifts, provide access between floors. Usually they only operate over two to three floors and are hydraulically, screw and nut or electrically operated.

They rely on hold to run operation and operate at slower speeds.

In both incidents the employees of organisations providing care to members of the public (non-employees) were allowed to use emergency lock release keys to open doors on upper landings during normal usage. The use of the key in this way allowed continued operation of the equipment under fault conditions. The emergency keys are intended to allow emergency access to the lifting platform in the event of people becoming trapped and should be under strict control.

As a result of inappropriate use of the emergency unlocking key during daily use of the lifting platform, access was gained to the lift well when the lifting platform was not at the same floor level.

This resulted in people accessing the open lift well and falling.

At one of the premises a resident died as a result of their injuries, and an employee was seriously injured.

Action required:

Organisations which have such vertical lifting platforms or lifts installed should review their procedures to ensure that emergency door release devices are not routinely operated during non-emergency situations. Emergency unlocking should be undertaken only in exceptional circumstances and by suitably trained and authorised people.

Safe working procedures and arrangements should be in place setting out what to do in the event of an emergency or failure. For example, how to deal with trapped people and the arrangements for repairing faults.

All lifts and lifting platforms must be inspected, serviced and maintained. Where the lift is used by work purposes, it must be thoroughly examined by a competent person. See link:  http://www.hse.gov.uk/work-equipment-machinery/passenger-lifts.htm

For more information, visit the HSE web pages http://www.hse.gov.uk/safetybulletins/liftingplatforms.htm#utm_source=govdelivery&utm_medium=email&utm_campaign=lifts-keys-23-nov&utm_content=safety-alert, http://www.hse.gov.uk/work-equipment-machinery/passenger-lifts.htm

or contact us on 07896 016380 or at fiona@eljay.co.uk, and we’ll be happy to help

Contains public sector information published by the Health and Safety Executive and licensed under the Open Government Licence

 

HEALTH & SAFETY NEWS UPDATE – 15TH SEPTEMBER 2016

We hope you find our news updates useful. If you know of anyone who may benefit from reading them, please encourage them to register at the bottom-left of our news page (http://www.eljay.co.uk/news/) and we’ll email them a link each time an update is published. If in the unlikely event any difficulties are experienced whilst registering we’ll be more than happy to help and can be contacted on 07896 016380 or at Fiona@eljay.co.uk

Scalding and burning – charitable company sentenced over injury to service user

A limited company providing housing support services for vulnerable adults and children has been sentenced, and fined £8,000, after a service user was burnt at one of its properties where five service users required 24 hour support with every aspect of day to day living including personal care.

In April 2015, a female 49-year-old service user with cerebral palsy, epilepsy and severe learning disabilities was assisted to a shower room by a support worker. During the Health and Safety Executive (HSE) investigation the radiator in the shower room was described as being very hot due to lacking an individual thermostatic control.

While the support worker was aware the radiator was hot, she did not consider it to be hot enough to burn. The support worker showered the service user and began drying her while she was sitting on a chair.

She then assisted the lady to step out of the shower area and take hold of a grab rail which was positioned above the radiator. While standing over the radiator her leg came into contact with the radiator.

As the service user is non-verbal and has difficulty balancing she was unable to move her leg away from the radiator or to communicate with the support worker to alert her. It is unknown exactly how long her leg was against the radiator.

The support worker noticed a burn on the left side of the injured lady’s left calf. She alerted the assistant team manager and the lady was taken to a specialist burns’ unit for treatment on the burn that extended 20 centimetres up her calf.

At a follow up appointment it was noted that the burn was not healing properly and a skin graft was taken from her thigh and applied to her calf. As a result the victim has been left with permanent scarring.

During the course of the investigation it came to light that the company had been alerted to the risk posed by the radiator. Following a routine inspection in November 2011 carried out by the local authority environmental health team, a written report required the radiator to be covered and a follow up email in 2012 asked whether the radiator in the bathroom had been provided with a suitable cover to protect clients from scalding.

Despite this being drawn to their attention, the court heard the company’s internal systems failed to ensure remedial action was taken. There was also a failure to carry out any general internal risk assessment regarding the danger posed by the radiator in question although an individual risk assessment in relation to the injured party identified that she was at risk from heat sources because she might not be able to move away from them easily or quickly.

Speaking after the hearing, HSE inspector Hazel Dobb said: “It was foreseeable that an unprotected, hot radiator could pose a risk to vulnerable individuals with reduced mobility and to those who could not react appropriately or quickly enough to prevent injury.

“There are several published sources of guidance on preventing burns and scalds which are available to download from the HSE website and we urge all dutyholders to visit the resource to help avoid such incidents in the future.”

Scalding and burning

Risks from hot water and hot surfaces

The health and social care sector often provides care and services for individuals who may be vulnerable to risks from hot water or surfaces. Those at risk include children, older people, people with reduced mental capacity, reduced mobility, a sensory impairment, or people who cannot react appropriately, or quickly enough, to prevent injury.

Risk of scalding

Health and social care settings have increased water temperatures for a number of reasons including the need to satisfy hot water demand, efficient running of the boiler and controlling the risk from Legionella bacteria. High water temperatures (particularly temperatures over 44°C) can create a scalding risk to vulnerable people who use care services.

Those who are vulnerable to the risk may be in hospitals and other care settings, care homes, social services premises and special schools. The risk of scalding/burning should also be assessed in community facilities such as hostels, or staffed and sheltered housing, where vulnerable people may be at risk.

Many accidents involving scalding have been fatal and have mainly occurred during bathing or showering. Where vulnerable people are at risk from scalding during whole body immersion, water temperatures must not exceed 44°C.  Any precautions taken should not introduce other risks, eg from Legionella bacteria.

Risk of burn injuries

Serious injuries and fatalities have also been caused by contact with hot pipes or radiators. Where there is a risk of a vulnerable person sustaining a burn from a hot surface, then the surface should not exceed 43°C when the system is running at the maximum design output.  Precautions may include insulation or providing suitable covers.

Further information

For more information visit the HSE web page http://www.hse.gov.uk/healthservices/scalding-burning.htm or contact us on 07896 016380 or at fiona@eljay.co.uk, and we’ll be happy to help

Contains public sector information published by the Health and Safety Executive and licensed under the Open Government Licence

 

 

HEALTH & SAFETY NEWS UPDATE – 5TH MAY 2016

We hope you find our news updates useful. If you know of anyone who may benefit from reading them, please encourage them to register at the bottom-left of our news page (http://www.eljay.co.uk/news/) and we’ll email them a link each time an update is published. If in the unlikely event any difficulties are experienced whilst registering we’ll be more than happy to help and can be contacted on 07896 016380 or at Fiona@eljay.co.uk

Safe use of bedrails (health services) – foundation trust fined over bedrail failures

A North West NHS Foundation Trust has been fined £100,000 over its inappropriate management of the use of bedrails at its hospitals.

Following a guilty plea in Carlisle Magistrates’ Court the District Judge referred the case to Carlisle Crown Court for sentencing.

HSE told the court that the Trust failed to ensure that they managed the risk of bedrails, which is a fundamental element of patient safety for which extensive and comprehensive guidance on risk, management and policies existed.

An initial HSE visit to the Trust in February 2012 identified issues with bedrail management, and a second visit in May 2012 resulted in the service of an Improvement Notice (IN) on bedrail management and a letter with recommendations.

The Trust identified actions to improve bedrail management, but failed to implement them. When the Trust was inspected in July 2013, inappropriate bedrails were found to still be in use and management systems were not appropriate to manage the risk. A further IN on identification and maintenance of third party bedrails was served.

The Court was told that the Trust had a policy on bedrail management but did not have the systems or procedures to underpin the implementation of the policy.

Elements of the failure were the lack of a system to identify and inspect third party bedrails; the lack of planned preventative maintenance on manual beds and bedrails; a lack of an effective system to rectify faults with inappropriate bedrails; lack of provision of appropriate training, and a lack of procedures to audit and monitor the effectiveness of the bedrail management system.

After the hearing, HSE Inspector Carol Forster said: “The need for adequate risk assessment and management of third party bedrails has been recognised in the healthcare sector for a number of years and guidance and advice has been published by the relevant bodies to this effect.

“Bedrails are used to protect vulnerable people from falling out of bed but the risks from inappropriate use of bedrails include the risk of entrapment by the head or neck, potentially leading to injury or asphyxiation.

“In this case there was a lack of management systems to recognise the risk of bedrails, apply standards and safety alert information, and a corporate failure to prioritise the need to manage bedrails effectively.

“The Trust failed to comply with the expected standards and I hope this case will send a strong message to others with responsibilities for bedrail management.”

Safe use of bed rails

What is the risk?

Bed rails, also known as side rails or cot sides, are widely used to reduce the risk of falls.  Although not suitable for everyone, they can be very effective when used with the right bed, in the right way, for the right person.

However, accident data shows that bed rails sometimes don’t prevent falls and can introduce other risks.

Poorly fitting bed rails have caused deaths where a person’s neck, chest or limbs become trapped in gaps between the bed rails or between the bed rail and the bed, headboard, or mattress.

Other risks are:

  • rolling over the top of the rail
  • climbing over the rail
  • climbing over the footboard
  • violently shaking and dislodging rails
  • violent contact with bedrail parts

Bed rails are ‘medical devices’, which fall under the authority of the Medicines and Healthcare Products Regulatory Agency (MHRA). MHRA enforces the Medical Devices Regulations and the General Product Safety Regulations to ensure medical devices are acceptably safe. MHRA guidance on the ‘Safe Use of Bed Rails’ (Device Bulletin DB 2006(06)) and details of when and how to contact them can be found on the MHRA website (https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency).

What do you need to do?

When bed rails are used during the course of a work activity, such as in a care home or hospital, the employer or self-employed person providing them must ensure that they are safe

Risks identified during inspection include:

  • trapping between poorly fitting mattresses and bedrails
  • rolling over the top of the bedrails when overlay mattresses reduce their effective height
  • trapping between the bedrail and mattress, headboard or other parts because of poor bedrail positioning.

Bed rails need careful management. Users should ensure:

  • they are only provided when they are the right solution to prevent falls
  • a risk assessment is carried out by a competent person taking into account the bed occupant, the bed, mattresses, bed rails and all associated equipment
  • the rail is suitable for the bed and mattress
  • the mattress fits snugly between the rails
  • the rail is correctly fitted, secure, regularly inspected and maintained
  • gaps that could cause entrapment of neck, head and chest are eliminated
  • staff are trained in the risks and safe use of bed rails

HSE advises users to take into account the dimensions in British standard BS EN 1970:2000 (to be withdrawn on 1st April 2013) and BS EN 60601-2-52:2010 when assessing risk and ensuring correct fitting. Manufacturers and suppliers of bedrails also have a duty to ensure that equipment is safe for use and you should refer to their instructions.

For more information, visit the HSE web page http://www.hse.gov.uk/healthservices/bed-rails.htm or contact us on 07896 016380 or at Fiona@eljay.co.uk, and we’ll be happy to help.

Contains public sector information published by the Health and Safety Executive and licensed under the Open Government Licence