NHS Trust fined £80,000 for window-fall death

10 October 2012

Walsall Hospitals NHS Trust has appeared in court after a pensioner sustained fatal injuries when he fell from an unprotected first-floor window at Walsall Manor Hospital.

Harry Riley, 71, was admitted to the hospital’s initial assessment unit on 18 January 2009, after suffering a mini-stroke. During the night, he disconnected himself from his drip and climbed up onto a table to open a window. He fell out of the window and landed on the ground. He suffered collapsed lungs, a fractured pelvis and multiple rib fractures and died the following morning owing to his injuries.

The HSE’s investigation found the hospital had failed to install a restrictor on the window to limit the opening of the upper sash to ten centimetres.

The Trust had also failed to carry out a proper risk assessment on the windows, despite receiving a safety alert from the Department of Health in 2007, which warned all hospitals about the risks of patients falling from upper-floor windows.

The alert, which was prompted by fall incidents, recommended that hospitals review all window restrictors and assess the potential risk from unrestricted windows.

HSE inspector Eve-Marie Edwards said: “The Trust should have known about the risk to patients of falling from windows. However, despite clear guidance, it failed to carry out an effective risk assessment.

“Hospitals must ensure that they have properly assessed the risk to patients of falls from accessible windows that can be opened more than ten centimetres.

“It’s essential that all such windows on assessment wards are properly restricted owing to the range of patients admitted, some of whom may be very vulnerable.”

Walsall Hospitals NHS Trust appeared at Wolverhampton Crown Court on 9 October and pleaded guilty to breaching reg.3(1)(b) of the MHSWR 1999. It was fined £80,000 and ordered to pay £26,917 in costs.



In mitigation, the Trust said it had no previous convictions and has subsequently fitted restrictors to windows at the hospital.



After the hearing, Walsall Hospitals NHS Trust chief executive Richard Kirby said: “I would like to offer my sincere condolences to the family at this difficult time. We acknowledge that prior to this incident there was an oversight in our evaluation of the potential risks, which the ward environment posed to confused patients. We would like to apologise for this failure.



“The Trust takes its health and safety responsibilities extremely seriously and immediately took steps following this incident to minimise the chances of a similar incident happening again.”
 

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a extremely unfortunate accident, which only re-iterates the importance of considering the additional risk posed when dealing with vunerable persons when carrying out risk assessments. I cant help but wonder if NHS cuts will result in further incidents of this nature, an obvious risk in hindsight, but how many risks are a body like the NHS having to deal with? are corners having be cut ? worrying times.
nhannaford@pdm-group
its good to hear they had no previous convictions but it makes you wonder something as small as a window restrictor in a risk assement of a room. how many near misses they had in the past with other ereas. surely it would be one of the first thing to asses if your of the ground floor when a patients needs are put into your care? height is one of the biggest killers in briton today.
elloboda@fsmail
A ridiculous prosecution of a one-off accident, which has cost the tax payer more than would have treated a dozen stroke cases. But, had the window casement not been obstructed by the desk; the window might have been opened safely, or perhaps if management stretched to better nursing on wards, Mr Riley might have had the window opened for him. Ah well, I expect we'll see some box-ticked, risk assessed notice of conformity, which perhaps might suggest padded cells and straight-jackets....
bill@heliosuk
regrets...oversight...sincere apologies! Even TravelLodge manage this correctly. Was this never picked up on safety tours especially in such a unionised place? £80k fine paid by the tax payer. Probably cost more than £80k to fix so all in all a saving to the trust. another case of "mind over matter" perhaps? We don't ind coz the patients (sorry..customers) don't matter!!
Filberton@aol
Given that my local PFI hospital's facilities management company charged £900 to install a digital TV aerial and socket in a rest-room (local aerial companies were quoting ~£150), then the bill for retro-fitting window restrictors could be much larger than the fine. Possibly heading into the grossly disproportionate region. @ Bill, some bright box-ticking spark probably put the desk in front of the window to keep people away from it; so they don't fall out or something daft like that!
andrew
Again, the tax payer picks up the bill, what is the point of handing out fines which don't hurt the pocket of the person responsible? until the courts start hitting where it hurts accidents will continue, and the NHS waiting list will grow longer.
paul

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