What happened
On 2 November 2014 Mary King, a support worker with the Liverpool agency Options for Supported Living, visited a resident at Fulwood Care Ltd on Ampthill Road, Aigburth, to discuss moving the resident’s care to Options.
The care plan was already written, by Liverpool Council, the NHS mental health trust and Fulwood Care together. It said no fewer than two carers should be with the resident at any time, and gave clear examples of the resident’s violence and aggression.
Nobody applied it. The Options employee, untrained for this resident, was left alone in the kitchen with the resident, who crossed the room and stabbed her in the right side of the neck with a blade.
The outcome
Options for Supported Living Ltd pleaded guilty at Liverpool Crown Court to breaching section 2(1) of the Health and Safety at Work etc. Act 1974, and was fined £31,000 with £10,000 towards costs. Fulwood Care Ltd pleaded guilty to breaching section 3(1) of the same Act, and was fined £14,000. A manager at Options accepted a formal caution.
HSE inspector Rose Leese-Weller said after the hearing: “This was a tragic and wholly avoidable incident.”
Ms King survived. The HSE said she had post-traumatic stress disorder and long-term psychological trauma, and was still receiving counselling.
What went wrong
The HSE found the warning had already been written down three times. Assessments and care plans from the council, the trust and Fulwood Care all flagged the resident as a high risk to themselves and to others.
Neither Fulwood Care nor Options took those documents into account before the visits. Options had not written its own risk assessment or care plan for this resident, had not identified the resident’s triggers, had not set a training plan for the staff who would meet them, and had not passed the paperwork on. Communication and supervision between the two agencies were inadequate.
The knowledge existed. The rule existed. The person at the door had neither.
What it teaches
A two-person rule on paper is worth nothing at the moment one worker is standing in a kitchen. What matters is what the worker does when the second one is not there.
That decision is made before the door. If the second person is missing, the visit does not happen, and nobody should have to weigh a rota problem against a resident whose file describes violence.
The second lesson is handover between agencies. A care plan is a control only once it reaches the person who will act on it, in a form they have read and been trained for.
Questions for the room
- You arrive and the second carer is not there. What does your service expect you to do?
- When did you last read the risk assessment for the person you are about to visit, rather than the task list?
- If a client’s file describes violence, what in your training tells you what the triggers look like in the room?
Evidence and limits
Confidence: confirmed. Three independent outlets (Liverpool Echo, HSE People, Health & Safety Matters) were read in full, with a case report and a Trades Union Congress bulletin, and they agree on the facts and figures. The findings on the care plan, the two-carer rule and the missing risk assessment are the HSE’s, not this page’s.
The manager who accepted a caution was not convicted and is not named. The stabbing is stated as the offence and no further detail is given.
Our lone working training covers what a risk assessment has to settle before one worker goes through a door alone.
Sources
- Liverpool Echo, 2021 · https://www.liverpoolecho.co.uk/news/liverpool-news/carer-stabbed-neck-dangerous-patient-20905640
- HSE People, 2021 · https://hsepeople.com/care-agency-fined-after-carer-was-stabbed-in-neck-by-dangerous-patient-after-being-left-alone
- Health & Safety Matters, 2021 · https://hsmsearch.com/news/care-providers-fined-after-employee-stabbed
- Croner case report, HSE v Options for Supported Living Ltd, Fulwood Care Ltd and a manager · https://app.croneri.co.uk/law-and-guidance/case-reports/health-and-safety-executive-v-options-supported-living-ltd-fulwood?topic=378
Reviewed 20 October 2026.