The Lincolnshire Partnership NHS Foundation Trust has been fined £20,000 and ordered to pay a further £6,864 after a mentally unstable patient was paralysed after diving headfirst from a roof.
The 26-year-old man who had a history of self-harm had been detained under the Mental Health Act at the Boston Pilgrim hospital; a facility operated by the Trust to provide acute care for the mentally ill. Boston Magistrates court heard how the patient had been escorted by staff to the ward’s garden so that he could smoke a cigarette. From here he managed on two occasions to climb onto a nearby roof. The staff talked him down and his smoking privileges were removed until the following day. The next day he was again escorted to the garden area, but as they arrived he sprinted across the garden and climbed on to the roof once more. He then finished his cigarette and dived headfirst from the roof, breaking his neck and causing permanent paralysis from the chest down.
An investigation by the Health and Safety Executive found that patients had regularly accessed the roof in the past but that nothing had been done to resolve the problem. No risk assessments were conducted in relation to self-harm in the garden area despite the log-book illustrating that situations had taken place there.
HSE Inspector Lyn Spooner said of the incident: “While the immediate cause of the incident was a failure to prevent a patient with tendencies for self-harming gaining access to the roof, the underlying cause at the heart of this case is the systematic management failings of the trust. Here was a vulnerable patient who had been detained under the Mental Health Act for his own safety, yet the necessary level of control needed to protect him from harm had not been achieved. As a result, he gained easy access to a roof, dived off and suffering life-changing injuries. What makes this worse is that he had been on the roof twice before, but had been talked down and there is a history going back many years of other patients gaining access to the roof.
“The Trust failed to recognise the significance of this and, as a result, ignored the very obvious warning signs that demonstrated the uncontrolled risk. This case highlights the importance of any organisation ensuring they have robust management systems in place so that risks are properly identified and controlled and warning signs do not go unnoticed.”
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