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June 28, 2021

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£1.5m fine for NHS Trust following failures to manage environmental risks

Essex Partnership University NHS Foundation Trust (EPUFT) has been fined for failing to manage environmental risks within its mental health inpatient wards. These breaches were committed by North Essex Partnership University NHS Foundation Trust (NEPUFT) before EPUFT came into existence.

Chelmsford Crown Court heard that, between 25 October 2004 and 31 March 2015, NEPUFT failed to effectively manage recognised risks from potential fixed ligature points in its inpatient wards, resulting in mental health patients being exposed to unacceptable and avoidable risk at a time when they were most vulnerable. Tragically eleven inpatients died during this timeframe whose deaths involved access to fixed ligature points.

The HSE’s investigation found that NEPUFT failed to adequately identify, or address with sufficient urgency, the significance of the environmental risks within its inpatient wards.

Essex Partnership University NHS Foundation Trust of The Lodge, Lodge Approach, Runwell Wickford, Essex pleaded guilty to breaching Section 3(1) Health and Safety at Work Act 1974. The Trust was fined £1,500,000 and ordered to pay costs of £ 86222.23.

Speaking after the hearing, HSE inspector Dominic Elliss said: “It has long been recognised that a key control in the prevention of inpatient death or self-harm is the identification and removal of potential fixed points of ligature from the ward environment. For a period of more than 10 years, NEPUFT repeatedly failed to manage these well documented risks, including learning from tragic experience, thereby needlessly exposing vulnerable patients in its care to unacceptable risk.

“I hope this case acts as a reminder to all mental health trusts of the need to continue to review their current arrangements and ensure their service users receive the protection they need at, what is often, their most vulnerable time.”

Det Chief Insp Stephen Jennings, the Senior Investigating Officer who led the Essex Police investigation into the North Essex Partnership University Foundation Trust (NEPUFT) welcomed today’s sentencing. He said: “I hope the conclusion of this HSE prosecution against NEPUFT, which we have supported throughout, now gives the families time to continue to grieve in peace.

“Following a full investigation, which began in 2017, into the circumstances of a number of deaths, and following expert legal advice, the evidential threshold was not met to allow us to take the Essex Police investigation any further. However, we ensured all of the evidence we had gathered was given to our HSE colleagues to support their investigation and it has unquestionably helped to secure this result.”

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Robin Dobson
Robin Dobson
6 months ago

NHS mis-management – Why was this well known and obvious hazard allowed to be a repeated failure – “For a period of more than 10 years”. From the information provided by this article this would appear to be negligence and, or incompetence, a failure of H&S inspections and audits, failure of management audits, failure of clinical audits, poor quality of staff training and supervision. 11 preventable deaths and £1586222 lost to the clinical care budget. Will there now be a Nationwide and urgent audit and remediation of this issue in all NHS Trusts and private hospital / facilities by the… Read more »

andy goodridge
andy goodridge
6 months ago
Reply to  Robin Dobson

Couldn’t agree more on your response Robin. The fact that a duty of care was not realised, or it was negotiated to satisfy the risks in their view within a clinical setting which evidently was high in category. A simple process of procedure and active monitoring could have easily prevented the terrible outcome.

Last edited 6 months ago by andy goodridge
6 days ago
Reply to  andy goodridge

Sadly, anyone who has ever had H&S or clinical responsibility for preventing self-harm or suicide by ligature will know that ligature risks in inpatient mental health services are recognised as being particularly difficult to manage. But there are systems and processes for minimising the risks and these should have been in use. The article doesn’t go into specifics but another media article says the court heard there were multiple failures in the risk management processes. It should be noted that this is one NHS trust (out of approx 223) and others should not be tarred with the same brush. Ligature… Read more »