Cygnet Health Care Limited fined just over £1.5m in prosecution brought by the Care Quality Commission over death of young woman

Published: 22 September 2023 Page last updated: 22 September 2023

Cygnet Health Care Limited has today (Thursday 21 September 2023) been fined £1,530,000 after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC), at The City of London Magistrates Court over the death of a young woman using one of their services.

Cygnet Health Care pleaded guilty to one offence of failing to provide safe care and treatment contrary to Regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at one of their facilities, Cygnet Hospital Ealing. They acknowledged failings of:

  • providing a safe ward environment to reduce the risk of people being able to use a ligature
  • ensuring staff observed people intermittently in line with the company procedures
  • training staff to be able to resuscitate patients in an emergency.

Cygnet has been fined £1,530,000 and ordered to pay £79,773.59 costs and £180 victim surcharge. This is the largest fine issued by a court to a provider of mental health services as a result of a prosecution brought by CQC.

In November 2018 a young woman was admitted to a ward in Cygnet Hospital Ealing. In July 2019, the young woman was able to take her own life while resident on the ward. Cygnet Ealing were aware of this young woman trying to harm herself in an almost identical way four months earlier, yet they failed to mitigate the known environmental risk she was exposed to.

CQC brought the prosecution as it believed that if Cygnet Health Care Limited had complied with its statutory obligations at Cygnet Hospital Ealing, this young woman would not have been exposed to such a significant risk of harm.

In order to protect people, it is a legal requirement for any provider of health and social care in England to comply with CQC regulations.

There are a number of enforcement actions CQC can and will take before prosecution to encourage and support improvement. People are entitled to receive safe care and treatment when they put their trust in health and care services, and providers should be held to account when significant avoidable failures occur.

Jane Ray, CQC deputy director of operations in London, said:

“This is a tragic case and my thoughts are with this young woman’s family and others grieving for their loss following her death.

“People, especially those at such a frightening, vulnerable time in their life, should be able to expect safe care and treatment, so it’s unacceptable that this young woman’s safety wasn’t well managed by Cygnet Hospital Ealing when she needed them the most. This is why I welcome their guilty plea.

“It is also unacceptable that Cygnet Ealing failed to learn from earlier incidents, which could potentially have avoided this tragic outcome. The judge also concluded that what Cygnet said would happen in line with their policy on observations and what actually happened in practice, were not the same thing.

“We know that the majority of people receive good care when they attend hospital, but if we find a provider has put people in its care at risk of harm, we take action to hold it to account and protect people in future.

“I hope this prosecution reminds Cygnet Health Care Limited, and other health and social care organisations they must provide care in a safe environment that meets people’s needs and starts to provide this young woman’s family with small degree of closure.”

Cygnet Health Care Limited was sentenced for this prosecution on 21 September 2023 at City of London Magistrates Court.

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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.