Norwich Crown Court heard how Mrs Joan Darnell, age 78, had been admitted as a patient to the Julian Hospital, on 28 September 2014 on the Blicking Ward, a specialist ward for patients suffering with dementia. On the 16 October Mrs Darnell was reported missing and was found face-down in a bath full of water in one of the bathrooms on the ward.
An investigation from the Health and Safety Executive (HSE) found that the Trust did not have sufficient policies or procedures in place for managing the safety of patients. They had failed to complete an appropriate risk assessment for Mrs Darnell and take steps to prevent vulnerable patients having unsupervised access to bathrooms. At the time of the incident the Trust did not have adequate systems and arrangements in place to ensure that patients under their care on the ward were effectively monitored. .
Norfolk and Suffolk NHS Foundation pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work etc. Act 1974 and fined £366,000 and ordered to pay costs of £12,888.48.
HSE Anthony Brookes, said “This was a tragic and preventable death. Had the trust put in place the correct procedures for the staff to manage the risks to vulnerable patients Mrs Darnell may still be alive. It is vital that patients’ needs are taking into consideration and Hospital Trust’s carry out appropriate risk assessments. They need to make sure the correct work systems are put in place to ensure they are managed but also appropriately monitored.”
