An NHS Trust has been fined £300,000 after a patient died after he fell 40m at the hospital where he was receiving treatment for psychosis.
Guildford Crown Court heard yesterday how Surrey and Borders Partnership NHS Foundation Trust had failed to protect Adam Withers, 20, who was admitted to Epsom hospital for treatment for acute psychosis.
Mr Withers was in the hospital courtyard with his mother on the day of the incident, 9 May 2014. A nurse from inside the ward was observing him when he started to climb up onto the conservatory roof.
The nurse immediately ran into the courtyard but was unable to prevent him climbing over the roof. He then climbed up a 130-foot (40m) industrial chimney. Attempts to talk him down failed and he fell sustaining fatal injuries.
HSE found the Trust had failed to learn from previous incidents in which patients could abscond via a low level building in the courtyard. There had been at least nine incidents between 2011 and 2014 in which patients had managed to get on to the roof, according to a report from the BBC.
HSE’s investigation found also there had been poor communication between staff and inadequate systems to ensure risks identified were addressed and remedied.
Fiona Edwards, chief executive of SBP NHS Foundation Trust, said they ‘fully accepted the judge’s decision and the fine’: “I am deeply sorry for Adam’s death and continue to offer my most sincere condolences to his family and friends for the devastating impact this has had on them," she said.
“This was a tragic accident and we accept responsibility for our contribution to his death. Sadly the loss of his life has helped drive, and contributed to, all of our safety work and service improvements.
“We have cooperated fully with the Health and Safety Executive to identify our failings and made significant changes to improve safety following this incident."
Speaking after the hearing, HSE Inspector Russell Beckett said: “The Trust failed to make appropriate changes following previous incidents. Had the Trust carried out a suitable assessment and made the appropriate changes they would not have allowed a vulnerable person the opportunity to end his life.”
Surrey and Borders partnership NHS Foundation Trust of Mole Business Park, Randalls Road, Leatherhead, pleaded guilty to breaching Section 3(1) of The Health and Safety at Work Act 1974 and was fined £300,000 and ordered to pay costs of £16,769.00.
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