Head Of Training, The Healthy Work Company

October 2, 2014

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NHS Trust fined after mental health patient jumps from roof

HSE has said that organisations must not ignore warning signs of uncontrolled risk following the prosecution of Lincolnshire Partnership NHS Foundation Trust. The trust was fined £20,000 for safety failings after a vulnerable mental health patient was left paralysed after diving off a roof.

The patient, who had a history of self-harm, had been detained under the Mental Health Act at Ward 12 of Boston Pilgrim Hospital, where the trust provides acute care for the mentally ill. The 26-year-old had twice before accessed the roof but had been talked down.

Boston Magistrates’ Court heard on 1 October that on 7 March 2013, a week after being admitted, the patient was twice escorted outside to the ward’s quad to have a cigarette, but on both occasions was able to climb onto a wall and the smoking shelter to get on to the roof of the single-storey building. He was talked down and his smoking privileges removed until the following day.

The next day, he was escorted to the quad by a nurse and nursing assistant. As they reached the doors leading to the quad, the patient sprinted to the roof giving staff no time to intervene.

He finished his cigarette and then dived off the roof on to the concrete floor below. He suffered a broken neck and a bleed on the brain leaving him permanently paralysed from the chest down. He now requires 24-hour nursing care.

A HSE investigation revealed a number of serious management failings at the trust which led to the incident.

The quad roof was regularly accessed by mentally ill patients over a five-year period. The trust was aware of this but nothing was done to resolve the problem and control the risks to patients who were intent on absconding or harming themselves.

No risk assessments were conducted in relation to self-harm in the quad area and a ward audit in November 2012 failed to identify any issues with the quad or the roof, despite an incident log being available to show there was a risk.

In addition, details of previous incidents had not been shared with the trust’s health and safety team.

Lincolnshire Partnership NHS Foundation Trust, of Lions Way, Sleaford, admitted breaching section 3(1) of the Health and Safety at Work etc. Act 1974 and was fined £20,000 and ordered to pay costs of £6,864.

Speaking after the hearing, HSE inspector Lyn Spooner said: “While the immediate cause of the incident was a failure to prevent a patient with tendencies for self-harming gaining access to the roof, the underlying cause at the heart of this case is the systematic management failings of the trust.

“Here was a vulnerable patient who had been detained under the Mental Health Act for his own safety, yet the necessary level of control needed to protect him from harm had not been achieved. As a result, he gained easy access to a roof, dived off and suffered life-changing injuries.

“What makes this worse is that he had been on the roof twice before, but had been talked down and there is a history going back many years of other patients gaining access to the roof.

“The trust failed to recognise the significance of this and, as a result, ignored the very obvious warning signs that demonstrated the uncontrolled risk. This case highlights the importance of any organisation ensuring they have robust management systems in place so that risks are properly identified and controlled and warning signs do not go unnoticed.”

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