NHS Trust Fined Following Patient Death
An NHS trust in the South West has been fined £200,000 after a patient fell to their death from a window.
Bristol Crown Court was told how Mr. Mark Scott-Green, an in-patient on the hospital’s Haygarth Ward, had become confused and vulnerable whilst he was staying at the facility.
It was found that the Trust authorised a Deprivation of Liberty Safeguard, which allowed them to forcibly return patients to their rooms for treatment in their best interest. On the 17th of November 2012 hospital security had returned Mr. Scott-Green to his room, he was later found on the lying in the courtyard having fallen from his second-floor window.
An investigation by the Health and Safety Executive (HSE) found that the window in the room that Mr. Scott-Green was staying in only had one window restrictor. The window was big enough to flex and the gap measures after the incident were larger than the recommended 100mm standard. It was also found that other windows on the same ward and across the Trust were not appropriately restricted.
Previously, a safety alert had been issued by the Department of Health to all NHS Trusts telling them about the risks of relying on just one window restrictor. Following the incident, the Trust were issued with an HSE Improvement Notice to ensure all the restrictors were suitable and prevented the windows opening more than 100mm.
Royal United Hospital (Bath) NHS Foundation Trust, Coombe Park, Bath, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974 and was fined £200,000. Costs will be decided at a hearing on the 19th of December.
HSE inspector Stephen Axt-Simmonds said, ‘Hospitals must take into consideration the confused mindset of some vulnerable patients when carrying out risk assessments. On this occasion, the Trust had already received clear guidance that a single restrictor was not suitable, but ignored the advice’
Go to the HSE press website to discover more about this incident and other HSE news.
Our comments:
A risk assessment of window restrictors needs to consider not only the risk of someone opening/falling out but also the extent to which they need to be robust. In care services where people have impaired capacity or are forcibly restricted to specific areas for their own safety, the duty is extended to include an assessment of how quickly and easily a standard restrictor could be removed to enable the person to get out. In this sad case, the assessment did not go that far, and the consequences proved fatal.
