Inspection and Regulation


Trust pleads guilty after patient seriously injured in ‘life-changing’ fall

A trust has admitted that it failed to provide safe care and treatment to people in its care after a patient was injured falling from the roof of one of its buildings.

The CQC announced that it would take action against the trust in March this year, and yesterday at Basingstoke Magistrates’ Court, Southern Health pleaded guilty to failing to provide safe care and treatment which resulted in serious harm to one patient, as well as putting others at risk of serious harm.

This was after an incident at Melbury Lodge, a psychiatric unit in Winchester that cares for those who have been admitted to hospital for severe mental health problems. In December 2015, the patient, called Mr AB, climbed onto the roof of the Lodge from the garden, and despite staff efforts to talk him down, jumped and received injuries that the CQC say will “affect him for the rest of his life”.

This happened after a similar incident with Mr AB in March 2012, when he slipped twice climbing on to the roof before he was restrained by staff.

Prosecutor Paul Greaney QC also described how since March 2010, a number of other patients had climbed on to the roof on no fewer than seven occasions.

Even after Mr AB’s accident, reports stated that three more patients managed to get on to the roof in February 2016 – one of them was injured doing this.

Despite these previous warning signs, Southern Health failed to safeguard their patients, and did not do enough to prevent another incident until April 2016.

A Southern Health spokesperson told NHE that the trust was clear that more should have been done to ensure the safety of patients in the trust’s care.

“We very much regret that injury was caused as a result, and have offered unreserved apologies to the patient involved,” they said.

Since the concerns were raised by the CQC, Southern Health’s own internal checks have been undertaken and after a comprehensive inspection at Melbury Lodge, anti-roll guttering was installed on the roof in May 2016.

“We are grateful to the CQC for recognising this work and removing the warning notice of which this risk formed part,” the spokesperson continued. “The safety and wellbeing of patients is our top priority, and we are continuing a number of programmes of improvement work to ensure that we can deliver safe and quality care across all Southern Health services.”

The case has been adjourned by the judge until 12 October, when a sentence will be issued.

Top Image: Melbury Lodge garden, c. Southern Health NHS FT

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