Lothian Health Board has been fined £220,000 for safety breaches, following the death of two vulnerable patients.
Both were being cared for at the Western General Hospital in Edinburgh at the time of their deaths.
One of the patients was found some five hours later in the hospital canteen preparation room having fallen from a first-floor window. Credit: HSE.
One of the patients, then aged 55, was in the care of the Neurosurgery Ward following an attempt to take his own life in which he sustained a head injury, on 29 October 2017.
While in the care of the ward he fell more than 11 metres to his death from a second-floor window. The window in his room was not restricted to the required 100mm opening gap.
The Health and Safety Executive (HSE) found that there was a failure to ensure that the patient was in a room which had windows that had been suitably restricted. The patient had undergone surgery which can cause confusion, delirium, and anxiety. It was considered to be foreseeable that patients in a state of confusion could be at increased risk.
On 23 January 2021, a second patient, then aged 79, was being cared for on the Medial Assessment Unit. He was presenting with hallucinations, confusion, distress and showing signs of delirium.
After multiple attempts to abscond over the following days, he left the ward and was found some five hours later in the hospital canteen preparation room having fallen from a first-floor window. He did not regain consciousness and his condition declined until he sadly passed away on 8 February 2021.
Plans to transfer the patient to a secure ward to manage his condition had been considered. However, at the time of his admission the transfer of patients between different wards in the hospital was strictly controlled in order to reduce the risks of Covid infections. He was therefore not transferred to a more suitable ward with the necessary security facilities to prevent him from absconding.
At Edinburgh Sheriff Court on 19 March 2024, Lothian Health Board pleaded guilty to breaching Regulations Section 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974. They were fined £45,000 in relation to the first incident and £175,000 for the second on 21 March 2024.
Speaking after the case, HSE Inspector Kerry Cringan said: “Two vulnerable gentlemen who were in hospital to receive care lost their lives in these tragic incidents. Lothian Health Board failed to ensure the risks patients of falling from windows were adequately managed.
“All companies operating in the health and social care sector are required to ensure that systems of work are in place to ensure those in their care are safe. The risk of falls from windows is well-known and there are standards for opening sizes that must be achieved. HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”
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