An 85-year-old man with dementia died when a care home lift plunged four metres into the basement because of poor maintenance, an investigation has found.
Kenneth Bardsley, who used a wheelchair, was taking the lift with a care worker at Serendipity Care Home, in Urmston, on January 30, 2017.
After the pair entered the lift on the first floor to take Mr Bardsley to the dining room on the ground floor, it stopped after a few seconds.
The corner of a damaged door caught on the lintel plate of the ground floor landing entrance — causing it to bend.
The lift was held up for a few moments until its weight caused the lift door to buckle, allowing the lift to drop four metres uncontrolled to the basement.
Sadly, the incident claimed the life of Mr Bardsley, and caused minor injuries to the member staff’s mouth, face, and left eye.
Now, an investigation has found that lift repairs at the Greenfield Avenue site were done to ‘a poor standard’ by Lancs and Cumbria Lifts UK Ltd.
Health and Safety Executive (HSE) inspectors said better communication could have ‘prevented this tragic incident occurring’.
Speaking after the hearing, HSE inspector Jennifer French, said: “This sad case involving a vulnerable resident and a care worker highlights the importance of good communication.
“If Lancs and Cumbria Lifts UK Ltd had been in receipt of the reports, which identified repeated faults, further opportunity would have been afforded to carry out the necessary repairs earlier and prevent this tragic incident occurring.
“Where several parties are responsible for the management of risk an effective system should be place to deal with reports of defects when they are identified.”
The HSE probe found that damage to the left-hand door of the lift had been reported to Lancs and Cumbria, responsible for the maintenance of the lift, a week before the incident.
Engineers from the firm had attended on January 23 to deal with the problem, and found that a part was required to complete repairs.
However, by the time of the incident no repair had taken place.
In the interim, Lancs and Cumbria went to the care home on the day of the incident for a planned quarterly maintenance visit, but did not follow up on repairing the door and the lift remained in use.
An HSE investigation found that mechanical repairs had not been carried out in accordance with good engineering practice and maintenance was of a poor standard.
Serendipity Care Home was owned by Premum Care Ltd, and was managed by its sole director, Tabinda Dahir.
Despite being fully aware of ongoing issues with the lift, she did not ensure that there was a system in place to deal with reports of defects — and nor was there a method of following up on work necessary to fix issues identified.
Whilst thorough examination reports had been carried out every six months, as required by law, these had not been provided by Premum Care to Lancs and Cumbria Lifts — and nor had they been requested by the lift maintenance company to inform its work, despite it being a contractual obligation for them to be provided with the reports.
Lancs and Cumbria Lifts UK Ltd of Douglas Bank House, Wigan Lane, Wigan Manchester pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974.
It was accepted that its failings had not been causative of the lift falling on January 30, 2017.
The company was fined £14,400 and ordered to pay £45,000 in costs.
Premum Care Ltd, of Greenfield Avenue, Urmston, Manchester went into liquidation shortly after the criminal prosecution began.
