An NHS Trust has admitted safety failings after a vulnerable patient died when he fell out of a hospital window.
Danny Jewitt, 45, who suffered with alcohol dependency and was prone to confusion, was admitted to Medway Maritime Hospital.
On 10 May 2009, he was in his first-floor room when he fell out of a window, which had been left wide open. He landed in a flowerbed five metres below and suffered serious chest injuries. He died later the same day from his injuries.
The HSE investigated the incident and identified that this was one of a number of unrestricted windows on the ward. The hospital is obligated under guidance to ensure all windows were restricted to a maximum opening of 10cm, in areas where vulnerable patients have access.
In October 2007, the Department of Health issued an alert requiring all NHS establishments to take action to fit window restrictors before 5 February the following year. Medway NHS Foundation Trust received this alert and identified a large number of missing or broken restrictors, but no action was taken.
In April 2008, the window in the room Mr Jewitt later occupied was flagged as requiring attention, but still no remedial action was taken prior to his death more than a year later.
The HSE issued an Improvement Notice to Medway NHS Foundation Trust, which required it to create arrangements to ensure restrictors were put in place and were properly maintained.
HSE inspector Liz Smith said: “The tragic death of Mr Jewitt was entirely preventable. The Trust knew the window in his room required urgent attention, and had a suitable restrictor been fitted in a timely manner then he would never have fallen in the way he did.
“Fitting window restrictors is a simple, inexpensive job that is proven to save lives. It is vital that all hospitals and care homes protect vulnerable people by ensuring windows open no more than 10cm.
“They also need to regularly monitor and maintain existing restrictors to ensure they are working and are in good condition.”
Medway NHS Foundation Trust appeared at Maidstone Crown Court on 25 January and pleaded guilty to breaching s3(1) of the HSWA 1974. It was fined £42,000 and ordered to pay £19,073 in costs.
In mitigation, the Trust said it has subsequently ensured all windows are adequately restricted and procedures are now in place to make sure they are maintained. It also said it cooperated with the investigation and had no previous safety convictions.
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Why was this not a CM case? The number of warnings received and failings by management is astounding! Once again, those acutually responsible for the poor culture and failure to manage known risks, get away with it. I imagine the FMgr has taken the brunt of the blame and others lower down the pecking order carrying the can.
A problem known for years. No excuse. Do they not do safety tours any more? These are sash windows so in old days the on-site hanyyman would just whack in a no.12 screw 6 inch above the lower sash as he walked around. 30 second job, max opening 6 inch at top, 6 in ch at bottom or 3 inch each….job done. (by today’s standards for 50p and 30 seconds read £millions and 2yrs of committee discussion!.
Totally agree with you Bob. The fat cats at the top still taking advantage of corporate lunches/functions I presume.
Everything is life is a trade off; The NHS now have to spend millions on adding window restrictors which comes out of their budget. Maybe that means they now have a few less nurses, so a man could no longer be seen to in time had a heart attack. Maybe that money could have been used to invest in some life saving equipment, but didnt so a few people died there in the future, where’s the cost benefit? It’s very easy to see what can be created to protect safety, but you never see what is destroyed