Mental Health Trust Fined £1.5 Million After Death Of 11 Patients

The Essex Partnership University NHS Foundation Trust has been fined £1.5 million after the Health and Safety Executive (HSE) successfully prosecuted it for failing to prevent suicides.  The Trust pleaded guilty to offences under the Health and Safety at Work etc Act 1974 and was ordered to pay costs of £ 86222.23.

The HSE investigation and prosecution followed the tragic suicides of 11 people between 1 October 2004 to 31 March 2015.  All patients died from hanging failed to effectively manage recognised risks from potential fixed ligature points in its inpatient wards, resulting in mental health patients being exposed to unacceptable and avoidable risk at a time when they were most vulnerable. 

Ligature points and health and safety risk assessments

Three quarters of mental health in-patients who kill themselves do so by hanging.  Therefore, it is vital that all Trusts have a robust risk management plan concerning ligature points. 

A ligature point is anything that can be used by a person to attach a cord, rope, belt, sheet, or other material that can be used for the purpose of hanging or asphyxiating themselves.  Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges, and closures.

Ligature points present an even greater danger if:

• They are located in an area where a patient would expect privacy, such as the toilet or shower room.
• It is between 0.7 metres and 4 metres from the ground.
• There is a persistent lack of duty staff and/or the layout of the ward makes it difficult to supervise vulnerable patients.

According to the Care Quality Commission (CQC), many warnings have been issued regarding the risk of fixed ligature points on mental health wards.  These include:

• In 2000, the report of the Chief Medical Officer, An organisation with a memory, instructed mental health trusts to remove all non-collapsible bed and shower curtain rails by March 2002.  Since 2009, suicide using non-collapsible rails has been a ‘never event’ which applies to all mental health inpatient settings.
• In 2012, the cross-Government strategy for preventing suicide in England called on mental health services to make “regular assessments of ward areas to identify and remove potential risks i.e. ligatures and ligature points”.

How did the Essex Partnership University NHS Foundation Trust breach the Health and Safety at Work etc Act 1974?

The Chelmsford Crown Court heard how the Trust failed to successfully oversee acknowledged risks from potential fixed ligature points in its inpatient wards.  This resulted in mental health patients being exposed to unacceptable and preventable peril at a time when they needed a high level of protection due to their vulnerable mental state.  

The Health and Safety Executive (HSE) found that the Trust did not properly pinpoint, or address with enough urgency, the importance of the risks posed by the fixed ligature points within its inpatient wards.

Speaking after the hearing, HSE inspector Dominic Elliss said:

“It has long been recognised that a key control in the prevention of inpatient death or self-harm is the identification and removal of potential fixed points of ligature from the ward environment. For a period of more than 10 years, NEPUFT repeatedly failed to manage these well documented risks, including learning from tragic experience, thereby needlessly exposing vulnerable patients in its care to unacceptable risk.

“I hope this case acts as a reminder to all mental health trusts of the need to continue to review their current arrangements and ensure their service users receive the protection they need at, what is often, their most vulnerable time.”

What actions do mental health providers need to take to mitigate fixed ligature related health and safety risks?

According to guidance by the CQC, in general inpatient wards, individual and ward risk assessments should include potential ligature points and any risks identified must be managed.  The same applies in psychiatric intensive care units.

To receive a Royal College accreditation, the unit would be expected to have undertaken an assessment of the necessity of any fitting that could be a potential ligature point. Where such fittings were unavoidable, they should not be able to bear a load of more than 20 kilos.

Medium secure services must meet NHS England standard contract for medium secure services states that services “will meet” the best practice guidance from the Royal College. This states that in medium secure wards:

• No ligature points in bathroom and shower areas.
• There is a system in place to formally assess the clinical environment twice a year (minimum) to ensure that ligature points are identified, and appropriate action taken.
• There is a system in place for staff to report any ligature points identified with prompt follow up action.

Staff should be trained on how to conduct an assessment for potential ligature points and keep a record of who has carried out the checks and when they were last done.

Concluding comments

Article 2 of the European Convention on Human Rights (ECHR) provides that ‘everyone’s right to life shall be protected by law’ and that ‘no one shall be deprived of his life intentionally’.  This puts a duty on all NHS health providers to ensure that their outpatient and inpatient premises are safe, and this includes ensuring that there are no fixed-ligature points in places where mental health patients may be placed.

Tanveer Qureshi specialises in white-collar crime and regulatory investigations and prosecutions.  If you require legal representation, please contact Tanveer directly at tqureshi@4-5.co.uk or via his chambers, 4-5 Gray’s Inn Square. for more about Tanveer or to subscribe to his newsletters, please go to www.tqlegal.co.uk