DuraLabel's Weekly Safety News

Blog Author Angelique Sanders

Weekly safety news. Stay in touch with regulations from OSHA, NFPA, and other safety codes. Find out about other companies' best and worst practices. We scour the internet to provide you with helpful training resources and the latest safety information.

Monday, May 05, 2014

World Safety News - Sweet Factory Fined

Workplace Safety News Highlights From Around The World

We scan newspapers and magazines around the world for safety news that isn't reported elsewhere.

The following are links to workplace safety-related news and articles that we noticed this past week. If you have international safety news, safety tips, or suggestions send them to: duralabelpro@gmail.com.

United Kingdom - Sweet Factory Fined Following Worker's Death

The UK's largest confectionery firm has been fined a total of £300,000 after an employee was crushed to death in one of its sweet-making machines.

The Health and Safety Executive (HSE) prosecuted Tangerine Confectionery Limited, of Vicarage Lane, Blackpool, following the death of employee Martin Pejril at its Poole factory. The company that manufactures sweets such as Sherbet Dip Dabs, Mojos, Black Jacks in addition to Butterkist popcorn appeared before Bournemouth Crown Court.

The court heard 33-year-old Mr Pejril, a Czech-born starch room operator, was clearing a blockage in one of the machines at Tangerine's Alder Road plant in Poole, in February 2008. He climbed into the
machine but as the mechanism restarted he became trapped. Mr Pejril subsequently died of his injuries and was pronounced dead at the scene.

The company was found guilty of breaches under Section 2 of the Health and Safety at Work etc. Act 1974 and of breaching Regulation 3 (1) (a) of the Management of Health and Safety at Work Regulations 1999.

The company was fined £150,000 for the HSWA charge and £150,000 for the regulations charge and ordered to pay full costs of £72,901.65.

Following the hearing, HSE inspector, Simon Jones, said: "This tragic case highlights the need to ensure that machines are safely isolated before any maintenance takes place so it cannot unexpectedly start up. Simply pressing a stop button does not adequately isolate a machine."

"If the machine in this case had been properly isolated from the electrical power source before Mr Pejril attempted to clear the blockage, this accident would never have happened."

"A proper risk assessment would have highlighted the dangers of entrapment. All employees need to be adequately trained in correct company procedures - whether it's for clearing blockages, operating machines or any other high risk activity."

United Kingdom: Care Provider Prosecuted Following Death of Patient During Restraint

Castlebeck Care (Teesdale) Ltd has been fined £100,000 after a patient died while being restrained using an unauthorised technique at a Nottinghamshire mental health hospital.

The Health and Safety Executive (HSE) brought the prosecution after Derek Lovegrove, 38, suffered a cardiac arrest at Cedar Vale, a 16-bed nurse-led facility for patients with severe challenging behaviour, in East Bridgford on 10 July 2006.

Mr Lovegrove had severe mental impairment. He was registered blind and had 75 per cent deafness in both ears. He had poor speech with limited vocabulary and communicated with staff using the Makaton system of signs and signals.

He was classed as a high risk patient because he was prone to aggression which included the destruction of property and violence towards both staff and himself.

Between June 2005, when he first moved to Cedar Vale from Rampton Hospital, and May 2006, there were 95 recorded incidents involving Mr Lovegrove with restraint being applied in 32 cases.

Nottingham Crown Court
Photo by: Alan Murray-Rust
Nottingham Crown Court was told during a two-day hearing (28 and 29 April) that minutes before his death he had been restrained for a short period of time by three support workers in the corridor after making a grab for two of them. After this, one of the staff took him back to his room to avoid further incident, one remained in the corridor and one went to the kitchen.

This left Mr Lovegrove in his room with one support worker. Mr Lovegrove grabbed him and pulled him down on top of him. The support worker remained on top of Mr Lovegrove while he thrashed around, at which point the support worker who had stayed in the corridor entered the room and took hold of one of Mr Lovegrove’s arms, allowing the other support worker to stand up. Mr Lovegrove was told he could get up but nothing happened. When staff realised he was not breathing they dialled 999, administered CPR and used a defibrillator, but paramedics pronounced him dead at the scene.

HSE’s investigation found the level of supervision and observation given to Mr Lovegrove immediately before his death, and more generally, was inadequate and not in accordance with his care plan. This stated he should have 2:1 observation, meaning he should have two carers positioned within arm’s length and able to see him at all times.

The investigation also found the hospital previously used restraint techniques known as MAPA (Management of Actual or Potential Aggression). But as a result of recommendations by the Healthcare Commission after an inspection at Cedar Vale in February 2006, Castlebeck decided to replace MAPA techniques with a different restraint method provided by a company called Maybo, designed to be more in-keeping with conflict avoidance.

Staff undertaking Maybo training had expressed concerns that the techniques would not be adequate to deal with the risks posed by Mr Lovegrove, so the company visited Cedar Vale and noted Maybo techniques were not being employed and there were inconsistencies in the approach by staff. The company also noted that those who had been trained had not rehearsed or practised their new skills.

The court heard that Mr Lovegrove’s care plan was out of date as it made no reference to Maybo techniques and instead referred to MAPA techniques, which staff had been advised against using. The care plan made no reference to Mr Lovegrove’s tendency to pull staff to the ground and gave no specific guidance as to how such potentially-dangerous situations should be handled. It also failed to focus on the need to monitor Mr Lovegrove’s well-being during restraint and failed to address the circumstances in which, if ever, it was appropriate to decrease Mr Lovegrove’s observations from 2:1 to 1:1.

Nursing staff were not responding to each situation where a holding technique was used on Mr Lovegrove, as required in his care plan. No nursing staff had responded to the incident in the corridor before the incident in his room when he died.

Staff were not adequately trained in first aid and no members of staff were trained in the use of the particular defibrillator available at Cedar Vale on the day Mr Lovegrove died.

Castlebeck Care (Teesdale) Ltd, now in administration, was fined £100,000 after being found guilty of breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974.

After the hearing HSE Principal Inspector Frank Lomas said: “The failings of Castlebeck Care (Teesdale) Ltd are substantial. They fell far below required standards of care. At the time of this tragic incident the breaches were relatively longstanding and had been the subject of specific warnings, which had not been acted on."

“There was a failure to implement specific recommendations relating to the management of Mr Lovegrove’s behaviour made in a report by Maybo in September 2005, and a failure to implement requirements and recommendations made by the Healthcare Commission following a visit in February 2006."

“The support worker should not have been left alone with Mr Lovegrove. If another member of staff had been observing as required by the care plan, it would have been less likely that events would have unfolded in the way they did. Consequently this would have reduced the risk to Mr Lovegrove and staff.”

Related past posts:
Workplace Safety Includes Offsite Bullying
Businesses Must Address Domestic Violence
World Safety News - Companies Change Attitude On Safety

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