NHS Trust Fined Following Failures to Manage Environmental Risks

An NHS Foundation Trust has been fined for failing to manage environmental risks within its mental health inpatient wards.

Chelmsford Crown Court heard that, between 25 October 2004 and 31 March 2015, the trust failed to effectively manage recognised risks from potential fixed ligature points in its inpatient wards, resulting in mental health patients being exposed to unacceptable and avoidable risk at a time when they were most vulnerable. Tragically eleven inpatients died during this timeframe whose deaths involved access to fixed ligature points.

An investigation by the Health and Safety Executive (HSE) found that the trust failed to adequately identify, or address with sufficient urgency, the significance of the environmental risks within its inpatient wards.

The trust pleaded guilty to breaching Section 3(1) Health and Safety at Work Act 1974 were fined £1,500,000 and ordered to pay costs of £ 86222.23.

Speaking after the hearing, HSE inspector Dominic Elliss said: “It has long been recognised that a key control in the prevention of inpatient death or self-harm is the identification and removal of potential fixed points of ligature from the ward environment. For a period of more than 10 years, this trust repeatedly failed to manage these well documented risks, including learning from tragic experience, thereby needlessly exposing vulnerable patients in its care to unacceptable risk.

“I hope this case acts as a reminder to all mental health trusts of the need to continue to review their current arrangements and ensure their service users receive the protection they need at, what is often, their most vulnerable time.”

Detective Chief Inspector Stephen Jennings, the Senior Investigating Officer who led the Essex Police investigation into the trust welcomed today’s sentencing. He said: “I hope the conclusion of this HSE prosecution gives the families time to continue to grieve in peace.

“Following a full investigation, which began in 2017, into the circumstances of a number of deaths, and following expert legal advice, the evidential threshold was not met to allow us to take the Essex Police investigation any further. However, we ensured all of the evidence we had gathered was given to our HSE colleagues to support their investigation and it has unquestionably helped to secure this result.”


For more information on this, and other legal cases, please visit: https://press.hse.gov.uk/2021/06/16/nhs-trust-fined-following-failures-to-manage-environmental-risks/
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