HMA v Lanarkshire Health Board

At Hamilton Sheriff Court today, 13 December 2016, Sheriff Daniel Kelly QC imposed a fine of £60,000 on Lanarkshire Health Board after the board pled guilty to breaching health and safety legislation following the suicide of a patient under a compulsory treatment order.

On sentencing, Sheriff Kelly made the following statement in court:

“It is mercifully rare for a health board to be prosecuted in respect of the death of a patient at a hospital. In this instance the death is unusual in that Jamie Maguire was intent on taking his own life, albeit that at the time he was extremely unwell and in the care of the hospital for his own protection.

Mr Maguire was in Ward 19 at Hairmyres Hospital in East Kilbride under a compulsory treatment order. Having absconded on several occasions, after he had returned to the ward on 21 November 2012 he was noted as feeling particularly down due to his return to hospital.

He was placed on constant observation due to an increased risk of suicide. Thereafter, at about 6.45 am on 23 November 2012 he was found dead in the bathroom of his room, having placed a belt around his neck which he had secured to the handle of the door, thereby hanging himself.

It is the failure to maintain constant observation in conjunction with the incorrect fitting of the door handle which are the substance of this breach of sections 3(1) and 33(1)(a) of the Health and Safety at Work etc Act 1974, to which the Board has pled guilty today.

Jamie Maguire’s mother and sister will have been much affected by his death at the age of 41.

Some considerable time ago he was diagnosed with paranoid schizophrenia. His history of self-harm and attempts upon his life had been extensive.

On 21 November 2012 his presentation had worsened upon his return to hospital and his consultant psychiatrist had alerted others in the team to this, leading to the constant observation requirement being imposed.

Despite this, there was a period between about 6.35 am and 6.50 am on 23 November 2012 when Mr Maguire was able to pass unobserved from his bed into the bathroom, where he hanged himself on the door handle.

A ligature risk assessment had been carried out in 2007. In 2008 the consequential work was effected. Anti-ligature handles were obtained and fitted.

These devices are used in a range of settings such as in mental health wards, prisons and detention centres. About 10,000 of the type fitted in the ward have been sold by the suppliers.

The handles ought to be fitted so that they point at a 45 degree angle downwards, moving to point further down if any weight is applied.

In 2008 the handle was installed incorrectly, at a 45 degree angle upwards. This meant that it turned to point upwards.

In the four years until Mr Maguire’s death no audit was performed to ensure that the handles were effective, nor was any review of the handles undertaken. This was in spite of members of staff raising concerns at the way in which the handles had been installed and taking this up with their line manager.

Lessons ought to be learnt from the failure to prevent Mr Maguire taking his own life in this manner in relation both to the installation of such devices and to the constancy of observation required. Steps have been taken to learn from this unfortunate occurrence and an alert has been circulated to health departments throughout the United Kingdom.

The Board has also reviewed and up-dated its observation policy. These efforts to address the defects which led to the death ought to be given credit, as should the co-operation shown by the Board with the investigation.

Militating against the Board is that it does have one prior instance of a breach of this provision, when a fine of £24,000 was imposed in 2012.

In assessing the risk of harm, the risk must have been considerable in that if the handles were incorrectly fitted the risk of harm created was one of death. This has to be viewed in conjunction with the failure to review the handles despite staff raising concerns and the failure to maintain constant observation.

Any fine must bring home to the health board the need to comply with health and safety legislation so that patients in Mr Maguire’s position are adequately protected. The prosecution does differ, however, from the more common ones under this Act in that, while acknowledging that Mr Maguire was unwell at the time, the death did not occur in the course of some other activity but rather at the hands of the deceased himself.

Of considerable significance, there has to be taken into account the impact which a fine will have for a health board in its provision of much needed services. It is this latter factor which leads me to make a substantial reduction in the fine imposed from that which would be applicable to another organisation.

While a discount ought to be applied in order to reflect this plea of guilty tendered to the section 76 indictment, it has taken over four years for the matter to be resolved.  Disclosure was provided to the solicitors acting for the Board on 17 March 2014. Mr Maguire’s family have had to wait patiently for a considerable time for a resolution of the prosecution.

Taking these factors into account, I will impose a fine of £60,000 modified from one of £80,000 to reflect the guilty plea.”