Boston Magistrates’ Court has fined a Lincolnshire NHS Trust £20,000 and ordered to pay costs of £6,864 after pleading guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974.
An investigation held by the Health and Safety Executive (HSE) into how a mentally ill patient suffered spinal injuries and was left paralysed after jumping off a hospital building, has highlighted serious safety failings.
The patient was detained under the Mental Health Act and after just one week was escorted by nursing staff outside to allow him to have a cigarette. On two occasions the 26 year old patient managed to jump up onto a wall and then onto a roof. Nursing staff managed to talk the patient down.
However, on the following day two members of personnel escorted him to the outdoor smoking area, the patient ran off and again managed to gain access to the roof. He jumped off the roof, breaking his neck and suffering a brain injury.
The HSE told the court that over the last five years several mental health patients had accessed the roof and although the Trust was fully aware of this nothing was done to remedy the situation. Furthermore, no risk assessments had been carried out to identify the risk of self-harming.
The Trust’s Health and Safety Team were not made aware of the any patients that had tried to access the roof.
Speaking after the hearing, HSE inspector Lyn Spooner said:
“While the immediate cause of the incident was a failure to prevent a patient with tendencies for self-harming gaining access to the roof, the underlying cause at the heart of this case is the systematic management failings of the trust.”
“Here was a vulnerable patient who had been detained under the Mental Health Act for his own safety, yet the necessary level of control needed to protect him from harm had not been achieved. As a result, he gained easy access to a roof, dived off and suffering life-changing injuries.”
“What makes this worse is that he had been on the roof twice before, but had been talked down and there is a history going back many years of other patients gaining access to the roof.”
“The Trust failed to recognise the significance of this and, as a result, ignored the very obvious warning signs that demonstrated the uncontrolled risk. This case highlights the importance of any organisation ensuring they have robust management systems in place so that risks are properly identified and controlled and warning signs do not go unnoticed.”