COI/W/375/09 18 September 2009
Organisations responsible for the care of vulnerable people must ensure that an effective risk assessment regime is in place and that any risks are properly addressed and managed, says the Health and Safety Executive (HSE)
The warning follows the death of an inpatient, Sylvan Money, who was found hanging in her room at the Bronllys Adult Mental Illness Unit in Brecon in January 2004.
Powys Local Health Board was prosecuted by HSE under section 3(1) of the Health and Safety at Work etc Act 1974. It pleaded guilty to the charge during an earlier hearing at Brecon Magistrates Court, and was fined £30,000 with £46,849.50 costs at a sentencing hearing in Merthyr Tydfil Crown Court on Friday (18 Sep).
The inquest into Ms Money's death ruled that she took her own life while the balance of her mind was disturbed.
An investigation by HSE revealed that the Trust or the Local Health Board failed to act on a risk assessment - carried out by the Trust's predecessor - that identified potential ligature points in the unit i.e. points where material could be tied by people intent on harming themselves by hanging.
HSE Principal Inspector Colin Mew said:
"Powys Local Health Board had a duty to provide a physically safe environment, but failed to do so. There was also no system in place to ensure that measures identified to eradicate risks to patients had actually been carried out.
"There is an even greater duty up on employers who care for vulnerable persons as was the case here."
Regional reporters should call the appropriate Regional News Network press office.
Issued on behalf of the Health and Safety Executive by COI News and PR Wales.
Regional reporters should call the appropriate Regional News Network press office who act as HSE's Press Office throughout Great Britain.
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