Head Of Training, The Healthy Work Company

August 5, 2016

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NHS Foundation Trust fined over patient death

Pennine Care NHS Foundation Trust has been fined for safety failings after a patient drowned during a canoeing activity event.  The 31-year-old, who removed his buoyancy aid and jumped into the water in an attempt to end his own life, had not been adequately assessed in terms of his suitability to attend the activity, the HSE said.

Mansoor Elahi, from Rochdale was an inpatient at Birch Hill Hospital when the incident occurred at Hollingworth Lake, Rochdale on 5 September 2013.

Manchester Crown Court heard how Mr Elahi was participating in a pre-arranged rafted canoeing activity provided by an outdoor activities centre in partnership with Pennine Care NHS Foundation Trust, when he removed his buoyancy aid and jumped into the water in an attempt to end his own life.

An investigation by the Health and Safety Executive found that Pennine Care NHS Foundation Trust had failed to carry out a risk assessment for the activity or to adequately assess Mr Elahi’s suitability to attend.

Mr Elahi’s family said: “Mansoor was a loving, caring and immensely pleasant son, husband, brother, uncle and friend. He never failed to make those around him happy and we feel that a massive piece of our life and soul has been taken away from us.

“This immensely difficult time, which has now spanned over two years, has left us with no choice but to unfortunately lose trust in the mental health services at Pennine Care NHS Foundation Trust. We cannot help but think that if it was not for these failings then we would still have Mansoor with us today. We hope and pray that some positive changes can come from these events so patients are no longer put at risk.”

Speaking after the hearing, HSE Inspector Caroline Shorrock said: “The Trust failed to adequately assess Mr Elahi’s suitability to attend the rafted canoeing activity. Mr Elahi’s actions were entirely foreseeable as he had tried to enter the lake on a previous occasion. Had the Trust carried out a suitable assessment they would not have allowed a vulnerable person the opportunity to end his life.”

Pennine Care NHS Foundation Trust of 225 Old Street, Ashton-under-Lyne, pleaded guilty to breaches of Regulation 3(1) of the Management of Health and Safety at Work Regulation 1999 and Section 3(1) of the Health and Safety at Work etc. Act 1974 and was fined £30,000 and ordered to pay costs of £51,223.88.

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