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Southern Health fined £125, 000 after patient is injured falling from hospital roof

12 October 2017
Southern Health NHS Foundation Trust
  • Media,
  • Hospitals,
  • Mental health hospital services

Southern Health NHS Foundation Trust has been fined £125, 000 by Basingstoke 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 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.

In June 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 Melbury Lodge treats patients with a range of conditions and disorders, including depression, manic episodes, schizophrenia and substance misuse problems.

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 in an attempt to abscond. The trust's own security review had recommended safety measures including blocking up gaps in a fence and fitting anti-climb guttering, but these improvements had not been made.

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. Although he survived the fall, he sustained serious neck injuries.

The court was told that even though the dangers had been known for years, the trust had not taken action to deal with the risks, apparently because there was no money to spend on the remedial work.

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 trust was fined £125,000 for failing to provide safe care and treatment and putting people at risk of avoidable harm. It was also ordered to pay the prosecution costs of £36,000 and a £170 victim surcharge.

Professor Ted Baker, Chief Inspector of Hospitals, said:

"There can be no excuse for this failure by Southern Health 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. There had been at least seven incidents before this - yet they ignored clear evidence from their own reports on safety and did little to prevent this dreadful accident. Even after this event, the trust was slow to take action. It was a false economy which has now cost the trust dearly – and with awful consequences for one man."

“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 provider that imagines they can cut corners on safety at the expense of their patients."


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Last updated:
12 October 2017

Notes to editors

  • At the first hearing on 29 June 2017, the Court ruled: “The Court prohibits the reporting of Mr. AB’s true name or address or the location(s) at which he receives medical treatment or of any matter that may result in his true name or address or the location(s) at which he receives medical treatment being identified. The order lasts until 12th October 2017 unless revoked before then. The purpose of this order is to protect the identity of Mr. AB”.
  • 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.
  • During an inspection in January 2016, CQC raised significant concerns about the environment at Kingsley Ward in relation to poor lines of sight, risks from patients absconding and ease of access to the low roof. We issued a Warning Notice requiring the Trust to improve its governance arrangements and make improvements to ensure people’s safety
  • During inspection in September 2016 we found that anti-climb guttering had been installed at Kingsley Ward to prevent patients accessing the roof, the fence had been fixed to reduce potential footholds, mirrors had been installed to reduce blind spots, and work on introducing anti-ligature fixtures and fittings had taken place.
  • This was 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.