NHS Trust Fined Following Death of Patient

Monday, 13th February 2017

A South West NHS trust has been fined £200,000 after a patient fell to their death from a window.

Bristol Crown Court heard how Mr Mark Scott-Green, an in-patient on the hospital’s Haygarth Ward, had become confused and vulnerable while staying at the facility.

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 17 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 ward’s window was only fitted with one restrictor. The window was large enough to flex and the gap measured after the incident was larger than the recommended 100mm standard. It was also discovered other windows on the same ward and across the Trust were not adequately restricted.

A safety alert had been previously issued by the Department of Health to all NHS Trusts informing them of 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 that they 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 they were fined £200,000. They will also have to pay full costs which have yet to be confirmed.

HSE inspector Stephan Axt-Simmonds said, “Hospitals must take into consideration the confused mind-set 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.”