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Care provider Transform Residential fined after Stourbridge man's avoidable diabetes death

A care company pleaded guilty to causing a resident avoidable harm after staff failed to tell his family how to control his diabetes one condition before a home visit during which he died.


Transform Residential Limited which ran Glasshouse College in Stourbridge was fined £14,000.

It was also ordered to pay a £181 victim surcharge and £8540.04 costs to the Care Quality Commission (CQC) which brought this prosecution.

Jake Baker had been a resident at Glasshouse College since November 2019. Previously he lived at Ruskin Mill College, run by the same provider. He lived with learning and behavioural disabilities as well as type 1 diabetes which was managed with insulin.

When Jake moved to Glasshouse College, a diabetes control support plan was handed over from Ruskin Mill College, which highlighted Jake needed staff support in his diabetes management and supervision when managing his blood sugar levels.

During December 2019, arrangements were made for Jake to visit his family from 24 until 30 December, which was the longest time he had stayed with them overnight. Staff didn’t provide any information to his family about how to manage Jake’s diabetes and his family had no experience or training in assisting him to manage his condition.

On December 30, 2019 during this family visit, Jake became unwell and couldn’t travel back to Glasshouse College as planned. He died the next morning from diabetic ketoacidosis.

The provider failed to have adequate systems and processes in place to ensure a safe handover of Jake’s care to his family during his stay. This included a failure to carry out a risk assessment, put in place a care plan or to hand over any information regarding his diabetes care.

Glasshouse College, now run by Ruskin Mill Trust Limited, is a specialist residential college and a shared lives service for young autistic people and people with a learning disability and/or mental health needs.

Ros Sanderson, CQC’s deputy director of enforcement, said: “Our sympathies are with those affected by the tragic, avoidable, passing of Jake.

“He had the right to be kept safe while under the care of Transform Residential Limited, even when on overnight visits, but in this case the provider failed in their legal duty to protect him from harm.

“Staff should have ensured all relevant risk assessments and information was handed over to Jake’s family so he could visit them in a safe and supported way. However, due to the lack of adequate systems in place sadly this didn’t happen, and the provider let Jake and his family down."

He added: “The majority of care providers do an excellent job. However, when a provider puts people in its care at risk of harm, we will take action to hold them to account and to protect people.

“This fine is not representative of the value of Jake’s life, and we hope that this prosecution brings some closure to his friends and family, and reassures them that his death was not their fault.

“This prosecution should also act as a serious reminder to all care providers, to always ensure people’s safety and manage risks to their wellbeing.”