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NHS board fined for patient death NHS board fined for patient death
(40 minutes later)
A health board has been ordered to pay more than £76,000 after a vulnerable mental health patient killed herself on a psychiatric ward.A health board has been ordered to pay more than £76,000 after a vulnerable mental health patient killed herself on a psychiatric ward.
At Merthyr Crown Court, Powys Local Health Board was fined £30,000 and must pay costs of more than £46,000 after the death of Sylvan Money in 2004.At Merthyr Crown Court, Powys Local Health Board was fined £30,000 and must pay costs of more than £46,000 after the death of Sylvan Money in 2004.
The board had admitted breaching the Health and Safety at Work Act 1974.The board had admitted breaching the Health and Safety at Work Act 1974.
Ms Money, 26, of Presteigne, hanged herself from a curtain rail at Bronllys hospital near Brecon, Powys.Ms Money, 26, of Presteigne, hanged herself from a curtain rail at Bronllys hospital near Brecon, Powys.
The prosecution rested on the board's failure to remove fixed ligature points from the psychiatric unit.The prosecution rested on the board's failure to remove fixed ligature points from the psychiatric unit.
Ms Money's father, Christopher, said after the hearing: "I do feel a sense of relief that I can now draw a fairly solid line underneath at least one aspect of the tragic events of the past five years.Ms Money's father, Christopher, said after the hearing: "I do feel a sense of relief that I can now draw a fairly solid line underneath at least one aspect of the tragic events of the past five years.
"Of course we will never, never forget Sylvan and it will always be very painful to remember what happened.""Of course we will never, never forget Sylvan and it will always be very painful to remember what happened."
The court heard that a series of warnings about ligature points at the acute mental illness unit were not acted upon.The court heard that a series of warnings about ligature points at the acute mental illness unit were not acted upon.
Ms Money had been admitted to the hospital after two earlier suicide attempts.Ms Money had been admitted to the hospital after two earlier suicide attempts.
Ms Money was on a psychiatric ward at the hospitalMs Money was on a psychiatric ward at the hospital
Rupert Lowe, for the Health and Safety Executive, said there appeared to be confusion between curtain rails around beds and above windows.Rupert Lowe, for the Health and Safety Executive, said there appeared to be confusion between curtain rails around beds and above windows.
Ms Money was initially put on a 15-minute observation, later changed to 30 minutes, after she was admitted in January 2004.Ms Money was initially put on a 15-minute observation, later changed to 30 minutes, after she was admitted in January 2004.
Following a three-week inquest in 2006, the coroner listed 36 errors which led to her death as he recorded a narrative verdict contributed to by neglect.Following a three-week inquest in 2006, the coroner listed 36 errors which led to her death as he recorded a narrative verdict contributed to by neglect.
Mr Lowe asked Judge Eleri Rees to allow Ms Money's father to read a statement to the court, although the move was "very uncommon".Mr Lowe asked Judge Eleri Rees to allow Ms Money's father to read a statement to the court, although the move was "very uncommon".
Mr Money recalled first taking his daughter to Bronllys, saying: "When I left her I sat in my car in the hospital grounds until I felt safe enough to drive as I was in floods of tears.Mr Money recalled first taking his daughter to Bronllys, saying: "When I left her I sat in my car in the hospital grounds until I felt safe enough to drive as I was in floods of tears.
"I had no idea that this would be the last time I would see Sylvan alive.""I had no idea that this would be the last time I would see Sylvan alive."
Judge Rees said the family should not feel any guilt for having entrusted their daughter to the hospital's care.Judge Rees said the family should not feel any guilt for having entrusted their daughter to the hospital's care.
"It's clear... there was a history of systematic, perhaps management failures that they [Powys Local Health Board] inherited from the previous trust," she said."It's clear... there was a history of systematic, perhaps management failures that they [Powys Local Health Board] inherited from the previous trust," she said.
She said a fine could not reflect the family's loss, and that she had to bear in mind she was sentencing a public body.She said a fine could not reflect the family's loss, and that she had to bear in mind she was sentencing a public body.
Public apology
The court heard the board, which has a budget of £235m, was facing a £20m deficit this year.The court heard the board, which has a budget of £235m, was facing a £20m deficit this year.
Public apology
Richard Tyrrell, for the board, apologised to the family after Mr Money asked the judge if he could hear it say sorry publicly.Richard Tyrrell, for the board, apologised to the family after Mr Money asked the judge if he could hear it say sorry publicly.
Mr Tyrrell said an apology had been made at the inquest, but that he "repeated it here without reservation".Mr Tyrrell said an apology had been made at the inquest, but that he "repeated it here without reservation".
In a statement, board chief executive Andrew Cottom, who attended the hearing with other bosses, said considerable work had been done to address issues identified in the case.In a statement, board chief executive Andrew Cottom, who attended the hearing with other bosses, said considerable work had been done to address issues identified in the case.
The Health and Safety Executive said 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".
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 on employers who care for vulnerable persons as was the case here."