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CQC prosecutes Southern Health after patient is injured falling from hospital roof

29 June 2017
Southern Health NHS Foundation Trust
  • Media,
  • Hospitals,
  • Mental health hospital services

Southern Health NHS Foundation Trust has appeared in court today (Thursday) to enter a plea to the charge that it failed to provide safe care and treatment to people in its care.

The Care Quality Commission brought the prosecution following an incident at Melbury Lodge, a psychiatric unit in Winchester that cares for people who need to be admitted to hospital as a result of severe mental health problems.

At Basingstoke Magistrates' Court 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.

Paul Greaney QC, prosecuting, said that since March 2010, a number of patients who had been detained under the Mental Health Act had climbed onto the roof from a courtyard area on no fewer than seven occasions, in an attempt to abscond.  The trust were well aware but did nothing sufficient to prevent this until April 2016.

In March 2012, one of the patients, Mr AB climbed onto the roof from the garden, twice slipping and nearly falling before he was restrained and brought down.

Three years later, Mr AB was readmitted to Melbury Lodge after his health deteriorated.  His family were so worried that he might again try to abscond that they asked the staff to keep a close eye on him.

In the early hours of the morning in December 2015 Mr AB again climbed onto the roof. Despite staff attempts to talk him down he fell to the ground and sustained serious neck injuries. He survived the fall, but with injuries which will affect the rest of his life.

Even after the accident three more patients were able to gain access to the roof in February 2016. One of them was also injured.

The judge has adjourned the case for sentence on 12 October 2017.


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Last updated:
30 June 2017

Notes to editors

  • Kingsley Ward is an acute inpatient service at Melbury Lodge. The 25-bed ward cares for those aged 18-65 who can no longer be supported at home and need to be admitted to hospital as a result of severe mental health problems.
  • This is the sixth prosecution that CQC has brought against providers since inheriting certain enforcement powers from the Health and Safety Executive and local authorities in April 2015.  It is the first prosecution of a NHS provider.
  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 describes a provider's duty to ensure that care or treatment is provided in a safe way. It is a criminal offence if the failure to provide safe care or treatment results in avoidable harm to a service user or exposes a service user to a significant risk of exposure to avoidable harm. It is one of a series of fundamental standards introduced following the Mid Staffordshire NHS Inquiry led by Sir Robert Francis.
  • The 2014 Regulations took effect on 1 April 2015 and coincided with a transfer of enforcement responsibility for health and safety incidents in the health and social care sector from the Health and Safety Executive and local authorities to CQC.

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.