On the night of 16 December 2021, Susan Greens, a resident at Springfield Bank Care Home, could not be found on the premises.

Following a search around the site in Bonnyrigg near Edinburgh, care assistants found the 95-year-old in her nightwear lying in an external courtyard. Mrs Greens had fallen and struck her head in the courtyard where she had been in the cold for some time.

She was admitted to Edinburgh Royal Infirmary and sadly died in hospital two days later.

An investigation by the Health and Safety Executive (HSE) found Mrs Greens died because she was able to access the courtyard while unsupervised and had fallen, spending up to an hour and a half outside before staff came to her aid.

Springfield Bank Care Home is run by HC-One Ltd and is a purpose-built care home offering nursing and nursing dementia care.

Guidance on Health and safety in care homes is available helping those providing and managing care homes a better understanding of the real risks and how to manage them effectively.

At Edinburgh Sheriff Court on 22 February, care home provider HC-One Limited of Archer Street, Darlington pleaded guilty to breaching Regulations Section 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. They were fined £400,000.

Speaking after the case, HSE inspector Kerry Cringan said: “This error cost a vulnerable old lady her life – families think that their loved ones will be safe in care.

“This was tragic and wholly avoidable. Had the doors been kept locked at night or had there been a system where staff would be told if the doors to the courtyard had been opened, the accident could have been avoided.”

A spokesperson for HC-One said: “Our heartfelt condolences and sincere apologies are with the family and loved ones of Ms Greens, who was a much loved member of our home.

“We are clear that this tragedy should never have occurred and that we absolutely must learn lessons from it. Following the accident in 2021, we comprehensively reviewed the safety and security of all our homes. Colleagues have received additional training around the themes identified in this case, new door alarms have been fitted to alert colleagues when an external door is opened so appropriate checks can be completed, and we have introduced additional monitoring and supervision practices.

“While we know that we cannot change what happened to Mrs Greens, we hope the hearing and the comprehensive action we’ve taken will bring her family a sense of closeure.”