NHS Health Board fined after failings resulted in man’s death

NHS Greater Glasgow and Clyde (NHSGGC) pleaded guilty at Paisley Sheriff Court to a number of failings, including not having a suitable risk assessment in place.

Martin Donnelly, 36, who had a history of mental illness, had been medically detained at the South Ward of Dykebar Hospital in Paisley, two days before his death.

An investigation by The Health and Safety Executive (HSE) established there had been failures by NHSGGC to ensure existing ligature points at the hospital were suitably and sufficiently risk assessed, and the patients under its care were not exposed to them.

NHSGGC had relied upon clinical measures, such as the assessment and observation of Mr Donnelly, rather than physical measures, to ensure his safety.

The NHS-issued guidance aligns with the terms of Regulation 4 of The Management of Health and Safety at Work Regulations 1999, and its ‘General Principles of Prevention’, which require the risks to be combated at source. In this case, that would have involved removing the certain  taps and other ligature points, or replacing them with suitable alternatives.

NHSGGC had a duty to keep Mr Donnelly safe and failed to do so. All reasonably practicable measures were not taken by NHSGGC, which could have prevented Mr Donnelly from taking his own life.

NHSGGC pleaded guilty to breaching sections 3(1) and 33(1)(a) of the Health and Safety at Work etc. Act 1974 on the 30 June 2023. At a hearing on 10 July 2023, it was fined £235,000 and ordered to pay a victim surcharge of £17,625.

Speaking after the sentencing, Inspector Lesley Hammond said: “The risks presented by access to ligature points in acute psychiatric wards are well known.

“Reasonably practicable measures could have been taken by NHSGGC to reduce the risk to patients, which would have involved the removal of obvious ligature points throughout the ward, as was undertaken after this incident.

“Had a suitable and sufficient risk assessment been in place before the incident and the results acted upon, Mr Donnelly would not have been able to take his own life in the way he did.”