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Avon & Wiltshire Mental Health Partnership fined £80,000 after patient is injured falling from hospital roof

21 August 2019
  • Media

Avon & Wiltshire Mental Health Partnership has been fined £80,000 by Taunton Magistrates’ Court after the trust admitted that it had failed to provide safe care and treatment to people in its care.

The Care Quality Commission brought the prosecution following an incident at Applewood Ward, an inpatient mental health ward unit in Swindon that cares for people who need to be admitted to hospital as a result of severe mental health problems.

On May 20 the trust pleaded guilty to an offence of failing to provide safe care and treatment resulting in avoidable harm to one patient and putting others at serious risk of avoidable harm.  Sentence had been adjourned until today.

The court was told that Applewood Ward is an adult acute inpatient service. This is a service for people whose health needs require specialist investigation, assessment and intervention

On 22 January 2016 an inpatient, gained access to a low roof area from the garden of Applewood Ward and declined to come down from the roof.

The emergency services attended the scene but were unable to persuade the patient to come down. Their partner and members of other staff were present throughout. After being on the roof for over eleven hours, the patient fell from the roof and sustained a number of serious injuries including an open fracture of their left femur, tibia fractures, along with facial, skull, jaw and nasal fractures

CQC told the court that there was a there were a number of failures in the care and treatment provided to the inpatient following their admission to Applewood Ward in January 2016.

This included the failure to assess risks posed by the roof to patients and do all that was reasonably practicable to manage any such risks. CQC believe that the harm caused to this person could have been avoided.

The risk of the low roof at Applewood Ward had been highlighted in previous annual risk assessments since 2011. The outcome was that the risk should be managed through staff observation. CQC believe this was an inappropriate and inadequate response to the risk posed to all service users by this low roof. In 2015 there were 28 direct references to the low roof in the garden of Applewood Ward between January and December at seven different Trust forums. The Trust was also aware that numerous other service users had been able to access the low roof prior to the service user’s fall in January 2016. 

The trust was fined £80,000 for failing to provide safe care and treatment and putting patient at risk of avoidable harm. It was also ordered to pay the prosecution costs of £12,033.96 and a £170 victim surcharge. 

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (and lead for mental health), said:

"There is no excuse for this failure by Avon & Wiltshire Mental Health Partnership to protect their patients from harm. Unfortunately, this was not an isolated incident – but part of a wider failure to deal with concerns over safety as they arose.

“The trust had failed to make basic improvements to protect the people in its care, despite having been aware of the dangers for years. They ignored clear evidence from their own reports on safety and as a result a patient suffered serious injury.  

“In the circumstances, we had no choice but to prosecute in the criminal courts.  I hope this case will serve as a warning to any other providers” 


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Last updated:
21 August 2019

Notes to editors


About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.