An elderly hospital patient suffered severe burns when staff inadvertently rolled her into contact with very hot radiator pipework, a court has heard.
United Lincolnshire Hospitals NHS Trust has been fined £100,000 after admitting a breach of Health and Social Care Act Regulations.
Boston Magistrates’ Court was told on Friday, March 25, that Iris Longmate – who was close to her 100th birthday – died 11 days after the incident at Lincoln County Hospital, although not as a result of the burns.
They were sustained during a resuscitation process on Greetwell Ward on March 3, 2019.
In light of the trust’s guilty plea, the Care Quality Commission, which brought the prosecution, withdrew a second broader charge involving the risk provided to other service users.
The court was told Mrs Longmate had been admitted to the hospital on February 19 and her condition worsened, including some confusion.
At around 12.30pm on the day of the incident she had been left for five to ten minutes while she used a commode.
Staff then found her face down on the floor, breathing but not alert.
Miss Stephenson, prosecuting, said: “Mrs Longmate was then turned on to her side and back in order to assess her.
“As a result of being turned, Mrs Longmate was pressed up against the exposed radiator pipework.”
The court was told that the temperature of the pipework was about 60 degrees Celsius. Health and safety guidance says contact with anything above 43 degrees can lead to serious injury.
Mrs Longmate suffered a burn to her left thigh measuring 30cms by five centimetres and a superficial burn to her arm.
She had suffered a fractured spine and cut to her head in the fall, which is believed to have happened after she had fainted.
Mrs Longmate was transferred to Queen’s Medical Centre in Nottingham two days later and died on March 14.
Subsequent checks on Greetwell Ward showed there were four radiators and 12m of exposed pipework which were considered a high risk and 19 radiators and 34m of pipework which were of medium risk.
The court heard moving extracts of written victim personal statements from family members, who were present in court, along with the trust’s chief executive Andrew Morgan.
Mrs Longmate’s daughter, Jeanette Hickman, said she had to leave the hospital room to gasp when she first saw the burn wounds and suffers nightmares reliving the sight of them.
David Longmate said he had found it difficult to come to terms with his mother suffering such injuries in a “perceived place of safety”.
Miss Sanderson, representing the trust, said she wanted to start her mitigation by expressing to the court the “deep regret” of the trust for the circumstances that led to the offence.
“And in particular the pain and suffering that was caused to Mrs Longmate and to her family,” she added.
“[The trust] extends its unreserved apology to her family.”
She said a number of actions and a “wholesale review” had taken place since the incident to ensure it could never happen again.
District Judge Peter Veits said: “This prosecution is for the failure of the hospital in not recognising and dealing with the danger caused by the hot pipes. Clearly, at that time adequate procedures were not routinely followed.”
He acknowledged that the trust had done a lot of work to improve the situation.
“But it is troubling in 2019, a hospital – which should’ve been a safe haven for those needing treatment – was not a safe place.”
The trust was also ordered to pay £11,205 in costs and surcharge.
Fiona Allinson, CQC’s deputy chief inspector of hospitals, said: “This death is a tragedy. My thoughts are with the family and others grieving for their loss.
“People have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by United Lincolnshire Hospitals NHS Trust.
“Had the trust addressed the issues with the exposed heating pipes before Iris fell, she wouldn’t have suffered such awful burns injuries.
“The vast majority of people receive good care when they attend hospital, but if we find a provider has put people in its care at risk of harm, we take action to hold it to account and protect people.
“I hope this prosecution reminds health and social care organisations they must provide care in a safe environment that meets the needs of patients, so they receive the safe care and treatment they deserve.”
ULHT chief executive Andrew Morgan said: “We would like to extend an unreserved apology to the family of Iris Longmate for the circumstances of her injury three years ago, and the pain and distress that she experienced.
“We have learned lessons from the incident, and would like to provide reassurance that action has been taken to address the risks from exposed radiator pipes at Lincoln hospital and across the Trust, to ensure that the events cannot be repeated.”