SIM 7/2007/07
Author Unit/Section: Health and Social Care Services Unit
Target Audience: Local Authority Health and Safety Enforcement Managers, Health and Safety Regulators, Regulators of Health and Social Care Services and Others
This SIM provides advice to Health and Safety Regulators (for clarity and convenience referred to as Inspectors) who are involved in the regulation of health and social care activities. The SIM addresses the continuing high number of fatal and serious injury incidents to people who use care services falling from windows in health and social care premises. It replaces SIM 07/2001/39.
1 Analysis of accident data has continued to highlight the serious issue of people who use care service falling from windows in health and social care premises. For consistency, the term ‘people who use care services’ has been used to describe patients, residents and any other clients in health and social care premises.
2 Health and Social Care Services Unit have identified at least 7 fatal accidents and approximately 30 major injury incidents attributed to falls from windows during the 2 year period 2002/03 to 2004/05.
3 There are 3 broad categories of falls:
4 Accidental falls are a minority, but can occur where a person is sitting on a window sill, or where the sill height is low and acts as a pivot, allowing them to fall out.
5 A significant number of reports refer to the mental state of people who use care services. In particular, senility, dementia, reduced mental capacity or illness, the effect of drink and drugs (both prescribed and illegal) can all cause anxiety and confusion. In these cases people who use care services have tried to escape from a perceived hostile environment, or to use a window believing it to be a door, possibly unaware that they are not at ground level. Other influencing factors include unfamiliarity with new surroundings, often exasperated by uncomfortable temperatures, anxiety, broken sleep and medication effects.
6 Deliberate self-harm is a recognised risk for some people with certain medical conditions. Inspectors are reminded that suicides can still be a matter for investigation, although they are not reportable under RIDDOR. The propensity to self-harm should be considered as part of the initial clinical assessment, particularly for psychiatric patients, and actioned as appropriate. In this and other cases, falls from windows are reasonably foreseeable and should also be addressed as part of the management risk assessment.
7 The health and safety of people who use care services is covered by the general requirements of Section 3 of the Health and Safety at Work Etc Act 1974, (HSW s.3) and by the risk assessment requirements of the Management of Health and Safety at Work Regulations (Reg 3) (MHSWR reg.3).
8 Workplace (Health, Safety and Welfare) Regulations 1992 introduce more specific requirements on windows. Regulation 14(1)(a) deals with the risk of falling through glazing material, and reg.15 applies to risks associated with the opening/adjusting of windows, skylights etc, including the risk of falling.
9 However, the Workplace Regulations are intended to protect people using premises as a place of work, and reg.15 should not be used to achieve the higher standard of protection required for vulnerable patients or other members of the public, i.e. that of preventing them climbing out of a window. The standards required under the Workplace Regulations are limited to those necessary for the protection of people at work.
10 Regulation 3 of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) requires that where a person not at work suffers a major injury (as defined in schedule 1 to the regulations ) or fatal injury out of or in connection with work must be reported to the relevant enforcing authority. Guidance on understanding the meaning of the phrase “Arising out of or in connection with work” is given in regulation 2(2)(c) of RIDDOR. Accidents involving people who use care services and falls from windows will generally be classed as ‘arising out of or in connection with work’ and will be reportable if they meet the above criteria. For the reasons outlined above, investigation may be justified even when self-harm is suspected. The application of RIDDOR and HSW Act s.3 need to be considered separately.
11 CSCI is the single, independent inspectorate for all social care services in England. Further information on their role with regard to health and safety of people who use care services can be found in SIM 07/2006/14 Better Regulation: Regulatory Bodies Inspecting Social Care.
12 In Scotland, the Scottish Commission for the Regulation of Care (the Care Commission) was set up under the Regulation of Care (Scotland) Act 2001 to establish a unified system of registration and regulation for social care services in Scotland including early education and independent and private health care. The Care Commission (CC) carries out regular inspections (at least twice a year for 24-hour care providers and annually, as a minimum, for others) to make sure that services meet the required minimum standards. Both HSE and CC have legitimate interest in matters concerning regulation in the care sector. However, because workplace health and safety is a reserved matter, HSE/LA inspectors in Scotland remain responsible for the regulation of risks to people who use care services arising out of or connected with work. A protocol, which will clarify the roles and responsibilities of HSE and CC is being developed.
13 In Wales the Care Standards Act 2000 and The Children Act 1989 (as amended) provide the National Assembly for Wales with the authority to register and inspect establishments and agencies in Wales that provide social care. The Care Standards Inspectorate Wales (CSIW), an operationally independent part of the Assembly regulates social care, early years and private and voluntary health care services. CSIW conduct regular (usually annual) inspections measuring services against National Minimum Standards produced by the Welsh Assembly Government. The National Minimum Standards address patient safety issues as well as the health and safety of care staff. A memorandum of understanding between HSE, LA’s and CSIW is being developed. CSIW will take the lead in enforcement in relation to any issue relating to the safety of people who use care services within the Care Standards Act and associated regulations; this will include the management of risks from hot water. Social Services Inspectorate for Wales will merge with CSIW to create the Care and Social Services Inspectorate (CSSIW) in April 2007.
14 Inspectors should look at the following elements of the risk management systems:
15 A risk assessment should consider the needs of the person using the care service and look carefully at all foreseeable situations that could give rise to risk. A legal duty is owed to psychiatric and other people who use care services for management to take reasonably practicable steps to minimise the likelihood of injuring or killing themselves.
16 Inspectors may face opposition from care home owners or possibly registration officers, who argue that, in order to create as ‘homely’ an environment as possible, windows should be capable of being opened wide, as in a domestic setting. Such arguments should be handled sensitively (see SIM 07/2007/10 “Balanced decision making for people who use care services. A balance has to be made to ensure the health and safety of an individual is not put at risk and that the independence of others is not unnecessarily curtailed.
17 A generic risk assessment may be appropriate if the client group is likely to change rapidly. It would not be practicable to reassess the risk and modify the controls each time a person uses the care service, enters or leaves the premises. However, individual risk assessment should be carried out if the generic risk assessment identifies potential for harm to vulnerable people who are likely to jump or fall. These issues should be borne in mind if compromises aimed at creating a more homely environment, as described in para 16, are made. However, care providers must give protection to the most vulnerable people in the premises.
18 Where the risk assessment warrants it, engineering controls should be provided as set out in paras 21-26 below.
19 Suitable arrangements should be in place to ensure control measures are in place and functioning properly.
20 Adequate training and supervision should be provided to ensure that staff understand the risks, precautions to be taken, and the need to report any difficulties to a responsible person.
21 Determining appropriate enforcement action requires HSE inspectors to reference the HSE Enforcement Management Model (EMM), Version 3.0 
. This is a fully open government document available at the HSE website
22 A judgement of actual risk will need to be made based on the vulnerability of the population who fall into the categories outlined in paras 4-6 and the control measures in place.
23 In a worst-case scenario of vulnerable people falling or jumping from a window at 2 metres or above, there is a risk of serious personal injury with likelihood probable to single casualties. Issues to consider when deciding the likelihood of incidents include whether there are vulnerable patients in first floor rooms of care homes, or first floor and above in hospitals, levels of supervision preventing access to some windows, and whether suitable control measures are identified at admission.
24 Where there are vulnerable service users and control measures are incomplete, there will always be a risk of serious personal injury with likelihood probable to single casualties from falls from windows at 2 metres or above.
25 Where all elements of the risk control system are in place, the permitted level of risk of injury is nil or negligible.
26 The risk gap should be determined using Table 2.1 of the EMM.
27 The following standards have been identified as ‘Established’ using the criteria set out in Table 3 of the EMM:
28 HS(G) 220 Health and safety in care homes - issued 12/01 (file 357) recommends:
29 NHS Estates Health Technical Memorandum No 55 Windows (1998) (available electronically via the NHS knowledge portal) recommends a maximum opening of 100 mm for use within reach of patients, particularly in areas for the elderly, those with learning difficulties or mental illness and is essential where windows are accessible to children. Restrictors should be types that can only be disengaged by means of a special tool or key. (The Scottish version is Estates Safety Action Notice SAN (SC)98/47 and Hazard Notice HAZ (SC)04/02).
30 BS 8213 – 1: 2004 Windows, doors and roof lights – Part 1: Design for safety in use and during cleaning of windows, including door-height windows and roof windows – code of practice. Paragraph 4.2 recommends that a risk assessment should be carried out on the building to establish the relative priority needs of the buildings windows including the design for safety in use. The risk assessment should take into account the type of occupancy and age range of both occupants and visitors to the building, where this can reasonably be predicted. If a significant change of use of the building occurs, the risks should be reassessed. Paragraph 5.4.1 recommends the fitting of safety restrictors to accessible opening lights where children or adults are at risk of falling out. Paragraph 3.14 defines a safety restrictor as a mechanical device, which is intended to limit the initial movement of an opening light so that a clear opening of not more than 100mm is achieved at any point.
31 Initial enforcement expectation is derived from Table 5.1 using the risk gap and standards established.
32 Inspectors should take into account previous advice, including any from the relevant intermediaries.
33 The hazards presented by falling out of windows to vulnerable people are well known and publicised. There are public interest implications to consider when determining appropriate action. Health and Social Care Services Unit promotes strong enforcement action where failings of risk management systems give rise to significant risk to vulnerable people who use care services. Inspectors should also consider that enforcement will have a positive impact on duty holders in the industry in general.
34 There have been a number of successful prosecutions following accidents to vulnerable people, including one where a fine of £20,000 was imposed following the death of an elderly resident falling from a window.
35 See also SIM 07/2008/03 - 'Balanced decision making for people who use care services'.
36 SIM 7/2001/39 - cancel and destroy.
