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A health board in Scotland has been fined £235,000 after a man took his own life while in its care on 22 January 2020.

The health board pleaded guilty at Paisley Sheriff Court to a number of failings, including not having a suitable risk assessment in place. The man who had a history of mental illness, had been medically detained two days before his death.

An investigation by The Health and Safety Executive (HSE) established there had been failures to ensure existing ligature points at the hospital were suitably and sufficiently risk assessed, and the patients under its care were not exposed to them. The board had relied upon clinical measures, such as the assessment and observation of the man rather than physical measures to ensure his safety.

The NHS-issued guidance aligns with the terms of Regulation 4 of The Management of Health and Safety at Work Regulations 1999, and its ‘General Principles of Prevention’, which require the risks to be combated at source. In this case, that would have involved removing the certain taps and other ligature points, or replacing them with suitable alternatives.

The board had a duty to keep the man safe and failed to do so. All reasonably practicable measures were not taken which could have prevented the man from taking his own life.

The board pleaded guilty to breaching sections 3(1) and 33(1)(a) of the Health and Safety at Work etc. Act 1974 on the 30 June 2023. At a hearing on 10 July 2023, it was fined £235,000 and ordered to pay a victim surcharge of £17,625.

Speaking after the sentencing, Inspector Lesley Hammond said: “The risks presented by access to ligature points in acute psychiatric wards are well known. Reasonably practicable measures could have been taken by NHSGGC to reduce the risk to patients, which would have involved the removal of obvious ligature points throughout the ward, as was undertaken after this incident. Had a suitable and sufficient risk assessment been in place before the incident and the results acted upon, the man would not have been able to take his own life in the way he did.”

Source – HSE

HSCS Scotland Promoting a Healthier Workplace Through Safety

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