NHS Ayrshire and Arran Health Board has been fined £50,000 for serious safety breaches after a mental health patient, who had been deemed at high risk of suicide, was able to hang herself using her own bootlaces.
Nicola Black, 33, died on 31 August 2010, the day after she was admitted to a mental health ward at Crosshouse Hospital, East Ayrshire, for care and treatment.
Kilmarnock Sheriff Court heard on 18 August that Ms Black had been assessed by a doctor of being at a high risk of suicide, self-harming and absconding from her room and as a result was to be kept under constant observation. However, despite this she died having used her bootlaces as a ligature, attached to a window restrictor which was secured to the top of the window of her hospital room.
An HSE investigation found that a number of failings had led to her death, these included:
• failure to remove the window restrictor;
• failure to communicate the risk of suicide to the relevant healthcare assistants; and
• a lack of specific policy regarding the removal of personal items such as bootlaces.
The Health Board had previously identified that restrictors, which stopped windows from opening more than 10cm to prevent absconding and falls, were at risk of being used as a ligature point. A contractor was asked to remove them from the hospital’s mental health wards but there was no record of the work being completed or of any check carried out of the work ordered to be done. The window restrictors in the room occupied by Ms Black were not removed.
Despite Ms Black needing to be under constant observation, the three healthcare assistants tasked with this had only been told the patient was at risk of absconding and were unaware of a suicide risk.
Part of the patient’s room could not be seen by the assistants and when Ms Black was out of sight the assistants looked in and saw her standing in the corner. At some point after this one of assistants looked in again and found the patient hanging.
The HSE investigation also found on admission to the ward there was no specific procedure or policy for checking and removing personal items (in this case boot laces) which may be used as a ligature.
NHS Ayrshire and Arran Health Board, Eglinton House, Ailsa Hospital, Dalmellington Road, Ayr, was fined £50,000 after pleading guilty to breaching section 3(1) of the Health and Safety at Work etc Act 1974.
Following the case, HSE inspector Jane Scott, said: “This tragic incident was both entirely foreseeable and preventable by NHS Ayrshire and Arran. Not only had their own assessment concluded that window restrictors posed a risk of being used as a ligature point and should have been removed, they knew that Nicola Black was at risk of self-harming or absconding from her room.
“In the first instance they failed to ensure work to remove the window restrictors had been carried out and in the second instance they failed to ensure the staff tasked with undertaking constant observation of the patient, not only did so but were aware of the reason for doing so.
“Finally, not having procedures in place to assess the suitability of personal belongings which could pose a risk to patients, compounded the safety failings which brought about this woman’s sad death.
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Strange as it seem, but it looks like among the failings HSE did not see reasons of her mental state…suspicious…
Is there not a contradiction here. On one hand it states that the patient had been assessed as being a high risk of suicide, self harming and absconding and yet it advocates the removal of window restrictors, which I would suggest increase the risk of harming and not mitigating the risk.
It would appear that the patient had not been adequately risk assessed upon admission and therefore appropriate control measures had not been implemented.
there seems to be an element of hindsight here. A person could self-harm themselves on almost anything. Ok, it may be easier with window restrictors.
Meanwhile, what sanctions have been taken against those who were tasked with care for the patient? Clearly there are individuals who did not perform their job properly and should be held accountable for their acts and omissions.