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Failing To Learn From Previous Death Results In Death Of Residential Care User

It is crucial to ensuring the health and safety of vulnerable service users in residential care, that the risk of drowning in the bath is identified and assessed, and appropriate controls put in place. It is pointless having a control plan on paper if a business does not implement it, says WorkSafe New Zealand.

That message comes after the service arm of the IHC New Zealand Incorporated, IDEA Services Limited was sentenced after the death of an intellectually disabled person in its care.

The company provides community residential support services to people with intellectual disabilities. In October 2016 a service user drowned after being left alone in the bath.

A WorkSafe investigation found that the company had not been implementing effective policies and procedures to manage the hazard of bathing vulnerable service users in its care.

WorkSafe’s Area Manager Paul West said that IDEA Services was aware of the risk to its service users of drowning in the bath.

“In 2014 an IDEA Services respite service user drowned after they were left alone in the bath. As a result of this incident, IDEA Services had updated its hazard register to include the risk of drowning. It introduced a control plan around providing baths to service users in care and specified that the level of support required for service users needed to be assessed on a patient by patient basis. Bathing service users is a task carried out regularly across the country and the controls to ensure the safety of the clients must be regularly and thoroughly reviewed.”

Despite this case, IDEA Services did not identify the risk posed to this service user from drowning in the bath, Mr West said.

“IDEA Services failed to ensure it developed and implemented effective information and guidance for workers on how to bath services users in a safe way. The Information provided to workers must be clear, practicable and be effectively communicated.

“The business also failed to ensure that homes that utilised baths were monitored to ensure the risk of bathing was being appropriately managed and that there was an effective system for information sharing between staff.

“It’s all well and good to have these plans in place, but unless they’re being implemented and risks are being properly managed, they are absolutely pointless.”

IDEA Services was ordered to pay a fine of $425,000 and reparation of $75,000 to the victim’s family.



  • IDEA Services Limited appeared in the New Plymouth District Court on Friday 23 July.
  • A fine of $425,000 was imposed.
  • Reparation of $75,000 was ordered.
  • Costs of $43,278 awarded to WorkSafe.
  • IDEA Services Limited was sentenced under sections 36(2) and 48(1) and (2)(c) of the Health and Safety at Work Act 2015.
  • Being a PCBU, failed to ensure, so far as reasonably practicable, that the health and safety of other persons, was not put at risk from work carried out as part of the conduct of the business or undertaking, namely providing supervision, oversight and/or assistance with the activities of daily living and personal care of its service users, and that failure exposed any individual, namely service users in its care, to a risk of death or serious injury from exposure to the hazards associated with bathing.
  • S 48(2)(c) carries a maximum penalty of $1,500,000.

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