Adam Withers, 20, who suffered from an acute psychotic illness died of severe head injuries after falling from the chimney in May 2014. He had previously told staff at Epsom Hospital he wanted to climb the ladder of the chimney. It was reported that there was a history of patients on the ward absconding by climbing over the roof of the ward beside the chimney, and Adam himself had previously done so.
An inquest found Surrey and Borders Partnership NHS Foundation Trust had failed to reassess his risk levels. The site of the chimney was left unsecured and the ladder was easily accessible, the inquest heard.
Surrey and Borders Partnership NHS Foundation Trust pleaded guilty at Guildford Crown Court and will be sentenced on 22 June.
The inquest jury concluded he had gone to the top of the structure and fallen from it unintentionally.
In a statement, trust chief executive Fiona Edwards said: “We are truly sorry for Adam’s sad death and I extend my heartfelt sympathies to his family and friends for his tragic loss of life and the devastating impact this has had on them.
“By pleading guilty today we accept that we have fallen short of the standards defined by health and safety legislation and we will continue to co-operate with the Health and Safety Executive to bring this case to a swift conclusion.”
Adam’s mother, Michelle Withers, who is also a Registered Nurse said: “We believed that Adam was in a place of safety and learning instead that his death should and could have been avoided has made his loss all the more distressing. Whatever changes have been introduced since, these will only ever be as good as the people on the ground whose job it is to care for people like Adam.”
Carolynn Gallwey, family solicitor said: “This was an avoidable death and demonstrates the importance of proper resourcing and high quality nursing in psychiatric care.