Newham Healthcare trust has been fined nearly£16,500 for breaching the Health and Safety at Work Act following an incident in which an 83- year-old patient fell to her death from an open window.
At the Bow magistrates court hearing, it was revealed that the east London trust had no risk assessment system of any kind in place at the time of the incident, a year ago.
The trust admitted the charges, but its solicitor asked the court to take into account its£4m operating deficit when sentencing.
It was fined£14,000 plus£2,471 in costs.
Health and safety inspector Bernadine Cooney told HSJ that the fine was one of the highest she had come across for deaths of this kind in healthcare settings.
She told the court that Health and Safety Executive inspectors were shocked by the 'lack of health and safety controls in place' when they visited the trust.
She said: 'When Frieda Smith was admitted to St Andrew's Hospital, her GP notes clearly stated that she was confused and a danger to herself.
'Interim patient assessment forms also show that staff were aware of this.
'At 6.30am on 16 October, the day after her admission, nurses found her bed empty. She was eventually discovered in the linen room, standing on top of a mattress, trying to get to the window.
'After this, the nurses requested window restraints for the ward - which had none at the time.
'But when the carpenter came to assess the windows it became clear that all of them needed restraints, and he had to go away and make them.
'At noon the same day a nurse, waiting in the grounds for a bus, looked up and saw Mrs Smith falling from a window.'
As far back as 1989, guidelines were issued to all trusts recommending that window restraints and electric doors be fitted for all wards housing vulnerable or confused patients.
In 1998 the guidelines became recommendations.
Newham Healthcare trust's solicitor, Elliot Woolf, said: 'When Kathren Watkins became chief executive at the end of 1997 she immediately contacted the HSE to try and establish a proper risk assessment system - but she had to start from scratch.
'There is now a risk co-ordination group, and this meets regularly with managers from all departments.
'Nearly 200 staff have been made risk assessors and started their training last year.'
In a statement, the trust offered its 'deepest sympathy and apologies' to Mrs Smith's family.