NHS Board sentenced after safety failings led to mental health patient suicide

We have previously reported on “want of care” incidents, whereby health authorities and private providers of health care were prosecuted for neglecting its patients.

NHS Ayrshire and Arran Health Board have been fined £50,000 after a vulnerable patient took her own life at a hospital in Kilmarnock. The health authority plead guilty to a breach of Section 3(1) of the Health and Safety at Work etc Act 1974.

Sheriff Murphy described Ms Black’s death as a “systematic failure” of management.

Nicola Black, 33, died the day after she was admitted to a mental health ward at Crosshouse Hospital, East Ayrshire. Ms Black had been assessed by a doctor as being at a high risk of suicide, self-harming and absconding from her room. She was to be kept under constant observation. However, she still succeeded in using her bootlaces as a ligature to hang herself off a window restrictor which was secured to the top of the window of her hospital room.

After investigation, the HSE found that a number of failings had led to the death.

Firstly, despite previously identifying that window restrictors were at risk of being used as a ligature point and instructing a contractor to remove them, there is no record of this work having been completed.

Secondly, the three healthcare assistants tasked with supervising Ms Black were apparently misinformed as to the patient’s psychiatric health. They were unaware of a suicide risk; only the risk of absconding was brought to their attention.

Thirdly, only part of the patient’s room was visible. When Ms Black was out of sight initially, the supervising assistants looked in and saw her standing in the corner. Shortly after this, one assistant looked in again and found the patient hanging.

Fourthly, the ward had no specific procedure or policy for checking and removing personal items (in this case boot laces) which may be used as a ligature.

HSE Inspector Jane Scott commented: “This tragic incident was both entirely foreseeable and preventable by NHS Ayrshire and Arran.”

This case follows on an increasing trend for the HSE to prosecute health providers, under existing health and safety legislation, for “want of care” of their patients.

Find more detail at http://press.hse.gov.uk/2014/nhs-board-sentenced-after-safety-failings-led-to-mental-health-patient-suicide/?ebul=hsegen&cr=17/26-aug-14