The Manager Is Responsible Too: Supreme Court Confirms Care Home Director’s Conviction for Fall Death
A care home director acquitted at trial has had a conviction confirmed by the Supreme Court — with the court finding that systemic failures in fall prevention education and emergency reporting procedures made the director criminally liable for a resident’s death, even though a care worker directly caused the fall. Here are the key points.
Issue
Where a care worker’s error causes a high-risk elderly resident to fall and ultimately die, can the care home director be convicted of occupational negligence causing death for systemic failures in fall prevention and emergency response — even without a specific regulatory mandate requiring two-person assisted transfers?
Facts
- B, a 94-year-old woman residing at a care home in Incheon, was being moved from her bed for bathing on June 8, 2023, when a care worker lost her grip and B fell to the floor.
- B sustained an intertrochanteric femur fracture and other injuries. The accident was not reported to the director until that evening — hours after it occurred. B was taken to hospital the following day, where surgery was recommended, but her family declined given her extreme age.
- B died approximately ten days later from an embolism — a complication of the fracture.
Lower Court Decisions
- The trial court convicted the care worker of occupational negligence causing death and sentenced her to one year imprisonment without labor, suspended for two years.
- The director was acquitted. The court found insufficient evidence of a specific two-person transfer requirement, and found the charges against the director did not sufficiently specify what concrete measures she had failed to take. It also found it difficult to establish causation between the director’s omissions and B’s death, given that B’s family had declined surgery.
- The appellate court reversed the director’s acquittal and sentenced her to six months in prison, suspended for one year, identifying three specific systemic failures.
First, despite a Ministry of Health and Welfare directive requiring care homes to conduct fall prevention education, the nursing assistant listed as instructor in the facility’s own fall education records testified in court that she had not actually conducted the training on the recorded dates — meaning the education records were fabricated.
Second, the facility had its own internal protocol requiring immediate reporting to a nurse and hospital transfer in the event of an accident — yet the reporting chain was so dysfunctional that the director was not informed until the evening of the day of the accident.
Third, B had already been formally classified as a high-risk fall patient — indicated by a “fall caution” sign posted at her bedside — yet there was no operational system in place to actually ensure two-person assisted transfers for high-risk residents.
Supreme Court Decision
- The Supreme Court (Criminal Division 1, presiding Justice Ma Yong-ju) dismissed the director’s appeal on July 16, 2026, confirming the six-month suspended sentence.
Key Takeaways
- A care home director’s criminal liability for occupational negligence is not limited to cases where the director personally committed a specific prohibited act. Systemic failures in training, supervision, and emergency reporting — for which the director is responsible — can independently establish criminal liability.
- Fall prevention education that exists only on paper — where records are fabricated and no actual training is conducted — is a significant aggravating factor that demonstrates the director’s failure to fulfill a ministerially mandated duty.
- A reporting system so dysfunctional that an emergency involving a high-risk resident goes unreported to the director for hours defeats the entire purpose of the protocol and reflects a failure of supervisory structure that the director is responsible for maintaining.
- Formal classification of a resident as a high-risk fall patient creates heightened obligations. The absence of any operational system to ensure protective measures are actually implemented for such residents goes beyond ordinary negligence.
- The family’s refusal of surgery does not sever the causal link between the director’s systemic failures and the resident’s death — the fall itself, which the proper supervision might have prevented, was the originating cause of the chain of events that ended in death.
Why This Matters
This ruling establishes that care home directors are not insulated from criminal liability simply because a front-line worker directly caused the incident. Where the director’s failures created the conditions in which the incident could occur and go unaddressed — through inadequate training, non-functional reporting chains, and absence of supervision for high-risk residents — criminal responsibility attaches at the managerial level. For care facility operators and their legal counsel, the case is a clear prompt to audit whether mandated education programs are actually being conducted, whether emergency reporting systems function as designed, and whether protective protocols for high-risk residents have operational substance rather than just paper existence.
Article: https://www.lawtimes.co.kr/news/articleView.html?idxno=225856
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