The owners of a Stamford care home where an elderly woman died have been fined £140,000 and ordered to pay £65,000 costs.
Staff at the Whitefriars Care Home in St George’s Avenue failed to notice that pensioner Dorothy Spicer, 84, had gone missing on the evening of November 25, 2009.
She was found eight hours later lying on the ground in the garden of the home still wearing her day clothes.
Yesterday at Lincoln Crown Court, The Order of St John Care Trust, which owns the home, admitted failing to ensure the safety of Mrs Spicer in breach of the Health and Safety at Work Act in November, 2009.
The court was told that Mrs Spicer had apparently walked out of a door which had its alarm disabled.
No check had been carried out to establish the whereabouts of any of the residents when the day shift handed responsibility over to the night shift at the home.
And the alarm system should have triggered pager messages to staff if a resident left the premises but this did not happen because the individual door alarm was not on.
Mrs Spicer was discovered at 5.20 am but staff simply took her inside the home and tried to warm her up. No ambulance was called for another 80 minutes and when she was finally admitted to Peterborough Hospital she was suffering from hypothermia.
She never fully recovered and although she was later transferred to Stamford Hospital she passed away two months later in January, 2010.
Judge Michael Heath, passing sentence, said: “In this case there were corporate, systematic and procedural failings which were ultimately a significant and substantial cause of Mrs Spicer’s death.
“The trust fell far short of providing a safe standard. Serious injury or worse was plainly foreseeable.
“It is only a matter of good fortune that no tragedy occurred before that which befell Mrs Spicer.”
Bernard Thorogood, prosecuting for South Kesteven District Council, said Mrs Spicer was last noticed at 8.30pm on the evening of November 25, 2009 sitting in her usual chair in a communal lounge at the care home. No-one saw her leave and she was only found the following morning.
Mr Thorogood said “This was exposure of vulnerable residents of a care home to avoidable risks.
“The investigation found failings that were corporate, systematic and procedural. These were a substantial cause of the loss of Mrs Spicer’s life.
“There was a lack of adequate leadership. There was a failing by management at the care home and from higher up within the trust.”
Prashant Popat QC, in mitigation, said the trust had an exemplary health and safety record prior to the incident and had since taken all steps to ensure a similar tragedy did not happen again.
He told the court: “The trust did consider and assess the risks to safety. It had in place a number of measures that it considered were sufficient to provide adequate protection. It could and should have done more.
“It’s health and safety record is excellent. The tragic incident involving Mrs Spicer is the first in it’s 22-year history.”
The district council’s portfolio holder for healthy environment John Smith (Con) said: ““We hope that the sentence in the case sends out a clear message that care for the elderly must improve so that avoidable events like the tragic incident involving Mrs Spicer and the suffering which her family have had to endure cannot happen again.”