Hugh Kearins, 77, had managed to leave the Chester Park Care Home in Glasgow via a series of stairways and fire doors. An inspector from the Health and Safety Executive (HSE) counted 320 steps from Mr Kearins’ room to the care home’s car park just off Lambhill Street, where his body was found at around 7am.

Mr Kearins, who had dementia, had been living in a room within the Clyde Unit of the home since 2012. As part of its investigation, HSE made enquiries regarding the use of an internal fire door and was unable to obtain corroborated evidence of who was last to use the door prior to Mr Kearins, who is thought to have exited through it just before 1am. The same door was closed about an hour later by an unknown member of staff carrying out routine checks.

It was confirmed by the care home manager that once the door was noted to be insecure, the member of staff should have initiated a head count of all of the residents to ensure their safety. However, this was not carried out.

The HSE investigation found the company had failed to have a safe system of work in place. Records held by the company in relation to Mr Kearins, extensively noted the clear risk that he might abscond or ‘wander’. It was part of his care plan that he be checked or monitored every hour.

HSE guidance states that the security of doors and gates should be considered where assessment identifies that specific residents leaving the premises will present a significant risk to their safety. It adds that in some instances it may be appropriate to consider devices that alert staff of their location and whether they are at risk of harm.

A senior care assistant and a care assistant who had responsibility for Mr Kearins’ care were also found to have falsified records, stating that they had performed tasks involving him at a time when he was in fact no longer in the home. Both were unaware he was no longer in his room until news of his death became known following the discovery of his body in the car park.

The management failures in respect of the alarm door reactivation were not causative of Mr Kearins’ death and would likely not have even come to light but for four individual errors:

• The unidentified member of staff who closed the internal fire door without further action;
• The fire alarm for the internal fire door which had been deactivated
• The unidentified member of staff who left the unalarmed external fire door insecure; and
• The actions of both the senior care assistant and the care assistant.

Oakminster Healthcare Limited, of Lambhill Street, Glasgow, pleaded guilty to breaching Sections 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. The company was fined £53,750 at Glasgow Sheriff Court on 23 July 2025.

HM inspector Amna Shah said: “This incident was completely avoidable. It is hugely concerning that a vulnerable man was able to walk so far and through so many doors without being noticed.

“We counted he had walked more than 300 steps. The fact this incident happened at Christmas time makes it all the more tragic. We will always take action against those who fail in their responsibilities.”

A spokesperson for Chester Park Care Home said: “The events surrounding the death of a much-loved resident in 2022 are tragic and our thoughts remain with their family and everyone impacted.

“Ensuring the safety and wellbeing of those in our care is our highest priority, and we deeply regret that, on this occasion, we fell short of that commitment.

“Following the incident, we immediately undertook a thorough review of all health and safety procedures, implemented rigorous staff training and strengthened our security protocols to ensure such a tragedy can never happen again.”