The owners of a Preston care home have been fined £65,000 following the death of a 40-year-old mother, who became trapped between a mattress and a bed rail.
Charlotte Young, who suffered from Huntingdon's disease, was found unconscious on 3 June 2008 at the Sue Ryder Care Home in Cuerden Hall, Bamber Bridge, and died later that morning in hospital.
Sue Ryder Care, one of the largest providers of palliative care in the UK, appeared in court after an investigation by the Health & Safety Executive found the home failed to manage the risks associated with the equipment used on Mrs Young's bed.
As her condition made her prone to involuntary movements, a specialist cushioning system was used along with the bed rails. However, Preston Crown Court heard the equipment was not used correctly by staff, creating a risk.
The HSE investigation found Mrs Young was able to knock her bed rail out of position because it was not the right size for her bed. This created a gap between her bed rail and mattress in which she became trapped and was unable to breathe.
David Shorrock, HSE Principal Inspector, said: "A mother has lost her life because of a systemic failure on the part of Sue Ryder Care at Cuerden Hall.
"Because the home was oblivious to the risks associated with this kind of equipment, they had no proper risk assessments in place. The maintenance of the equipment was also poor and staff were not trained to spot any problems which could have arisen in Mrs Young's case.
"I would urge care providers to carry out regular risk assessments on all their equipment to make sure the way it is being used is fit for purpose and continues to meet the needs of residents."
Sue Ryder Care, of King Street in Sudbury, Suffolk, pleaded guilty to breaching Section 3(1) of the Health & Safety at Work Act 1974 after it failed to manage the risks associated with the use of bedrails. It was ordered to pay £35,000 towards the cost of the prosecution in addition to the fine on 27 June 2011.