£300,000 fine following death of 14-year-old patient

Lewes Crown Court heard how Amy, who had complex mental health care needs, had been a patient in the high dependency unit (HDU), upper court, at Priory Ticehurst House Hospital since 24 August 2012. She had been transferred to the East Sussex facility after one of several attempts to ligature at home.

On 12 November 2012, Amy was found with a ligature around her neck in her room. The 14-year-old was taken to hospital but had suffered irreparable brain damage and failure of multiple organs, so a decision was taken to withdraw life support. Amy was sadly pronounced dead the following day, on 13 November.

An investigation by the Health and Safety Executive (HSE), which began in 2016 following the coroner’s inquest, found Priory Healthcare Ltd had failed to identify or put in place control measures that would have better managed ligature risks.

Priory Healthcare Ltd of Hammersmith Road, London pleaded guilty to a breach under Section 3 (1) of the Health and Safety at Work etc. Act 1974. The company has been fined £300,000 and ordered to pay costs of £65,801.38.

Speaking after the hearing, inspector Michelle Canning said, “This is a heart-breaking case. Our detailed investigation uncovered a number of failures. Our thoughts remain with Amy’s family and we are so very sorry for their loss.”

HSE found the company’s main failings were as follows:

• Failure to carry out a suitable and sufficient risk assessment relating to the presence of ligature points and ligatures on upper court;
• Failure to identify the control measures necessary to reduce ligature risks, so far as is reasonably practicable;
• Failure to consider relevant industry and NHS guidance to inform its risk assessment process and determine the correct fixtures and fittings for units where patients were at high risk of self-harm and suicide;
• Failure to ensure an adequate review was carried out of the systems and control measures relating to ligature risks at Ticehurst House following concerns raised by external bodies;
• Failure to ensure all staff working on upper court were trained and their work practices appropriately monitored with respect to life support techniques.