Anthony Pinder, who had learning and behavioural issues, was physically restrained for 90 minutes by staff at the Old Vicarage nursing home in Stallinborough, on 1 October 2004. When he was eventually released, he crawled to his room and was found dead a short while later. The staff themselves were not criticised, as the investigation established that staff at the centre, who were employed by Health and Care Services (UK) Limited, were not trained to carry out the safe physical restraint of patients. The techniques which were used at the Centre were described as “inappropriate and dangerous” but ultimately the failure to train staff rested with the management. The HSE also established that the Commission for Social Care Inspectorate highlighted the urgent need for safe restraint training only five months before the incident. Despite a written response from the senior management to that recommendation, no steps were taken.

Health and Care Services (UK) Limited admitted breach of section 3(1) of the HSWA 1974 and were fined £80k and ordered to pay costs of £40,823.