An NHS board has been fined £50,000 for serious safety breaches after a mental health patient was able to hang herself.
Nicola Black, aged 33, died on 31 August 2010, the day after she was admitted to a mental health ward at Crosshouse Hospital, East Ayrshire, for care and treatment.
Kilmarnock Sheriff Courtwas told on 18 August that as a result of a doctor’s assessment that she was at high risk of suicide, self-harming and absconding, Ms Black was to be kept under constant observation. However, she subsequently hanged herself with her bootlaces, which she attached to a window restrictor in her room.
A Health and Safety Executive (HSE) investigation found NHS Ayrshire and Arran Health Board had previously identified that window restrictors, which stopped windows from opening more than 10cm to prevent absconding and falls, were at risk of being used as a ligature point. A contractor was asked to remove them from the hospital’s mental health wards but there was no record of the work being completed or of any check carried out of the work ordered to be done.
The HSE also found that despite Ms Black requiring constant observation, the three healthcare assistants tasked with this were told only that she was at risk of absconding and were unaware of a suicide risk. Part of her room could also not be seen by the assistants.
On admission to the ward, there was no specific procedure or policy for checking and removing personal items – such as bootlaces – that could be used as a ligature.
NHS Ayrshire and Arran Health Board was fined £50,000 after pleading guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974.
Following the case, HSE Inspector Jane Scott said: “This tragic incident was both entirely foreseeable and preventable by NHS Ayrshire and Arran”.
“Not only had their own assessment concluded that window restrictors posed a risk of being used as a ligature point and should have been removed, they knew that Nicola Black was at risk of self-harming or absconding from her room”.
“In the first instance they failed to ensure work to remove the window restrictors had been carried out and in the second instance they failed to ensure the staff tasked with undertaking constant observation of the patient, not only did so but were aware of the reason for doing so”.
“Finally, not having procedures in place to assess the suitability of personal belongings which could pose a risk to patients, compounded the safety failings which brought about this woman’s sad death”.
This tragic case underlines that even the largest organisations can fail to ensure compliance with health and safety requirements, with devastating consequences. Health and safety requires ongoing attention from employers to ensure their policies, procedures, risk assessments and training are kept up to date.
At Palmers, we can provide comprehensive advice and guidance to help employers meet their legal health and safety obligations. For more information on how Palmers can assist you with health and safety issues, or if you are facing prosecution, please visit the Palmers website or contact our health and safety specialists Lara Murray and Jeremy Sirrell.