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The Royal United Hospital (Bath) NHS Foundation Trust has been fined £200,000 after a patient fell to his death from the window in his room.

Bristol Crown Court heard how an in-patient on the hospital’s Haygarth Ward had become confused during his stay at the facility in November 2012. The Trust had authorised a ‘Deprivation of Liberty Safeguard’ allowing them to forcibly return the patient to his room for treatment in his best interest. On the day in question he had been returned to his room by hospital security staff, but was later found dead in the courtyard underneath the window to his room.

When the Health and Safety Executive investigated the incident, they found that the only window in the room was fitted with only one restrictor. The window was large enough to flex and when the gap was measured after the incident, it was found to be larger than the 100mm recommended standard. Other windows around the ward were also not adequately restricted. The Department of Health had previously issued a safety alert regarding window-opening restrictions, but no action had been taken. Subsequently the Trust was issued with an HSE Improvement Notice to ensure that all window restrictors were suitable and prevented the windows being opened more than 100mm.

Speaking after the hearing 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.”

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