• Avon and Wiltshire Mental Health Partnership Trust fined £80,000 after being prosecuted by CQC for failing to provide safe care 
  • CQC’s prosecution prompted by incident involving a patient falling from the roof of one of its wards 
  • Is third trust to be prosecuted by CQC for breaching fundamental standards 

A trust has been fined £80,000 following prosecution by the Care Quality Commission for failing to provide safe care.

The CQC prosecuted Avon and Wiltshire Mental Health Partnership Trust over an incident where a patient sustained serious injuries falling from the roof of its Applewood Ward in Swindon in 2016.

In May this year, the trust pleaded guilty to the charge of “failing to provide safe care and treatment resulting in avoidable harm to one patient and putting others at serious risk of avoidable harm”. Yesterday, it was fined £80,000 by Taunton Magistrates’ Court and ordered to pay the prosecution costs of £12,033.96 and a £170 victim surcharge.

According to a statement from the CQC, the incident involved a patient who, in January 2016, gained access to a low roof area from the garden of the trust’s Applewood Ward and, after 11 hours, fell from the roof, sustaining serious injuries. The statement added: ”The risk of the low roof at Applewood ward had been highlighted in previous annual risk assessments since 2011. The outcome was that the risk should be managed through staff observation.

“CQC believe this was an inappropriate and inadequate response to the risk posed to all service users by this low roof. In 2015 there were 28 direct references to the low roof in the garden of Applewood Ward between January and December at seven different trust forums. The trust was also aware that numerous other service users had been able to access the low roof prior to the service user’s fall in January 2016.”

Paul Lelliott, deputy chief inspector of hospitals and lead for mental health, said: “There is no excuse for this failure by Avon and Wiltshire Mental Health Partnership to protect their patients from harm. Unfortunately, this was not an isolated incident – but part of a wider failure to deal with concerns over safety as they arose. 

“The trust had failed to make basic improvements to protect the people in its care, despite having been aware of the dangers for years. They ignored clear evidence from their own reports on safety and as a result a patient suffered serious injury.” 

In a statement Dominic Hardisty, chief executive for Avon and Wiltshire Mental Health Partnership Trust, said: “A patient suffered from harm whilst under our care and we offer them our sincere apologies for this. We let them and the NHS down, and have subsequently embarked upon a significant programme of changes to prevent something like this happening again.

“We are continuing to work with NHS England to ensure that funding is made available for further improvement works needed. In the meantime we are carefully planning care and managing risk of harm on a patient-by-patient basis.”

This is the third criminal prosecution of an NHS trust carried out by the CQC for breach of the fundamental standards, which were brought in following the Mid-Staffordshire care scandal.

All prosecutions involved mental health trusts. The first prosecution took place in 2017 when Southern Health Foundation Trust was fined £125,000 and told to pay £36,000 in costs after a patient under its care fell from one of its buildings. The second prosecution was against Sussex Partnership FT, which was fined £200,000 for an incident involving the death of a 19-year-old prisoner.