Health board fined £220,000 after two patients died in window falls at hospital
A health board has been fined £220,000 for safety breaches after two patients died when they fell out of hospital windows in separate incidents, the Health and Safety Executive (HSE) has said.
NHS Lothian was handed the penalty over the death of two men, aged 55 and 79, while they were being cared for at the Western General Hospital, Edinburgh.
The 55-year-old died on October 29, 2017, having been in the neurosurgery ward following an attempt to take his own life, during which he sustained a head injury.
While in the care of the ward, he fell more than 36ft to his death from a second-storey window. The window in his room was not restricted to the required 100mm opening gap.
The HSE said an investigation revealed a failure to ensure the patient was in a room with suitably restricted windows.
The HSE also said the man had undergone surgery which can cause confusion, delirium and anxiety, putting him into a category of increased risk.
The 79-year-old was being cared for at the hospital’s medical assessment unit on January 23, 2021.
He was experiencing hallucinations, confusion, distress and delirium.
Having tried to escape the ward over the course of several days, he eventually succeeded.
Hospital staff located the man unconscious around five hours later in the canteen preparation room, having fallen from a first-floor window.
He did not wake up and his condition declined until he died on February 8, 2021.
HSE said the hospital considered moving the man to a secure ward to manage his condition, however this was strictly controlled at the time in order to reduce the risk of Covid-19 infection.
In turn, the man was not transferred to a ward better suited to prevent him from absconding.
HSE said Lothian health board was fined £45,000 for the first incident, and £175,000 for the second at Edinburgh Sheriff Court on Thursday having pleaded guilty to breaching the Health and Safety at Work etc. Act 1974.
HSE inspector Kerry Cringan said: “Two vulnerable gentlemen who were in hospital to receive care lost their lives in these tragic incidents.
“Lothian health board failed to ensure the risks patients of falling from windows were adequately managed.
“All companies operating in the health and social care sector are required to ensure that systems of work are in place to ensure those in their care are safe.
“The risk of falls from windows is well-known and there are standards for opening sizes that must be achieved.
“HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”
NHS Lothian has apologised to the families of both men, and said a number of actions have been taken to prevent similar incidents from occurring in future.
Dr Tracey Gillies, medical director at the health board, said: “Following these incidents, a range of immediate actions were undertaken.
“Comprehensive reviews were also carried out to ensure that lessons could be learned and processes changed in caring for patients.
“We once again apologise to the families of both patients.”
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