Foundation health trust fined £20,000 after man left paralysed by Pilgrim Hospital wall ‘dive’

Boston Pilgrim Hospital. ENGEMN00120130924102319
Boston Pilgrim Hospital. ENGEMN00120130924102319

A public health trust was today ordered to pay a total of £26,984.90 for safety failings when a Pilgrim Hospital mental health patient was left paralysed after ‘diving’ off a roof onto a concrete floor.

Representatives from Lincolnshire Partnership NHS Foundation Trust appeared at Boston Magistrates’ Court after crown prosecutors charged them with breaching health and safety regulations on and before March 8, 2013.

Prosecutor Simon Belfield said a 26-year-old man, who had a history of self-harm, had been detained under the Mental Health Act at Ward 12 of Boston Pilgrim Hospital where the trust provides acute care for the mentally ill.

He had previously been seen at Lincoln Hospital after threatening to kill himself while living at the city’s YMCA.

Magistrates were told that on March 7, 2013, a week after being admitted, he was twice escorted outside to the ward’s ‘quad’ to have a cigarette, but on both occasions was able to climb onto a wall using the smoking shelter to get on to the roof of the single-storey building.

He was talked down on both ocassions and his smoking privileges removed until the following day.

Mr Belfield said that the next day, he was escorted to the quad by a nurse and nursing assistant. As they reached the doors leading to the quad, the patient sprinted to the roof giving staff no time to intervene. One nurse managed to brush his foot with her hand as he climbed the shelter.

After about four minutes, Mr Belfield said he finished his cigarette and then ‘dived off the roof on to the concrete floor below’.

He suffered a broken neck and a bleed on the brain leaving him permanently paralysed from the chest down. He now requires 24-hour nursing care.

Following the incident a Health and Safety Executive (HSE) investigation, along with an internal one by the trust itself revealed a number of failings at the trust which led to the incident.

It found the roof had been accessed by patients on seven times over the previous five years, however, no risk assessment had been done on the garden area and the risks hadn’t been raised to upper management due to communication issues.

Defending Iain Daniels said the trust accepted the failings but said it had worked fast to remedy the situation following the incident - removing the shelter and escalating the priority of putting systems in place to ensure communication between departments in the ward.

He said the ward had previously been commended and awarded on its achievements and said its reputation had already been affected by the incident.

He asked the magistrates to take into account that the trust was a public body and that a sizeable financial penalty could affect the services it provides to people.

The trust, based on Lions Way, Sleaford, admitted breaching Section 3(1) of the Health and Safety at Work etc Act 1974 and was fined £20,000 and ordered to pay costs of £6,864.