Hospital trust fined £180,000 after patient suffers burns from warming mattress

Overview of incident

An anaesthetised patient suffered debilitating injuries when a saline bag caused a warming mattress to reach temperatures high enough to cause full thickness burns. The sensor intended to monitor the mattress temperature was in contact with the cold saline bag providing an inaccurate reading that prompted the equipment to continue heating. The injured person received burns to his hip and buttock as a result of the incident at Maidstone Hospital on 25 September 2012.

The injured person required skin grafts at a specialist burns unit and was unable to work for almost five months and also suffered a mild heart attack that was likely to have been attributed to the successive operations.

Details of fine

Maidstone and Tunbridge Wells NHS Trust was fined a total of £180,000 and ordered to pay a further £14,970 in costs after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974.

An investigation by the Health and Safety Executive (HSE) identified failings with the way the warming equipment was used.

The court was told that Trust staff did not have sufficient information and training to ensure the heated mattress was used correctly to the manufacturer’s instructions.

Injured Person(s)

Mike Wilcock, 56.

Company Involved

Maidstone and Tunbridge Wells NHS Trust


Kent, England


Maidstone Crown Court


Mr Wilcock suffered a serious debilitating injury that was entirely preventable had the Trust implemented a better system and procedures to ensure the warming mattress was used correctly.

While the precise circumstances of what happened are somewhat unusual, it is entirely foreseeable that failing to ensure that staff know how to use a piece of equipment may have a negative outcome.

The risk of injury from warming devices is well documented, and it also well known that anaesthetised patients require extra care and attention because they are not able to respond and react as they ordinarily would. – HSE Inspector Dawn Smith

What should have been a simple operation has left me disfigured and has disrupted my life and that of my family.

My case highlights the critical nature of suitable and adequate training for staff in how to use and maintain equipment.

It also highlights that even with the most dedicated staff in the world things can go wrong, and when they do it is absolutely vital that a full and open investigation is carried out and that lessons are learned. – Mike Wilcock