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Southend hospital trust fined over fatal fall

Date:
1 July 2013

Southend University Hospital NHS Trust has been prosecuted for serious safety breaches after a vulnerable patient fell from a third floor window to his death in July 2010.

Robin Blowes, 69, from Blackmore in South Essex, died after falling nine metres through a window that was fitted only with a single restrictor. He had only recently been moved to a separate room for his own safety after becoming confused and agitated.

Southend Crown Court heard today (1 July 2013) that Mr Blowes was admitted for a bladder operation in June 2010. During his recovery he developed signs of confusion and was moved to a side room when his symptoms worsened. A security guard was posted outside to ensure he did not leave the ward.

On the evening of 4 July, Mr Blowes fell through the window opening in his third floor room. He sustained serious injuries and was treated in the hospital’s emergency department where he died the same evening.

An investigation by the Health and Safety Executive (HSE), which brought today’s prosecution, identified that Southend University Hospital’s arrangements for managing the risk of patients falling from windows were inadequate.

HSE found the window of Mr Blowes’ room was fitted only with a single, angle bracket restrictor, which was bent to one side allowing the window to be fully opened.

Guidance has been in place since 1989 stating that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of just ten centimetres to prevent falls.

The court was told that Southend Hospital reviewed its window restrictors following a previous incident in 2007 when a patient broke an ankle after jumping from a first floor window. A report carried out by the Trust in 2009 made a recommendation that ‘…chain link restrictors or similar should be fitted to all metal casement windows…’. However this was not followed through and at the time Mr Blowes died the window was still fitted with a single, inadequate restrictor.

Southend University Hospital NHS Foundation Trust, of Prittlewell Chase, Westcliff-on-Sea, Essex, pleaded guilty to breaching Regulation 3(1) of the Health and Safety at Work etc Act 1974. The Trust was fined £15,000 with £15,000 in costs.

After the hearing, HSE inspector Edward Crick said:

"The tragic death of Mr Blowes was entirely preventable. Had a suitable window restrictor been provided, as it should have been by the Hospital Trust, he would not have been able to defeat it and open the window wide enough to fall out.

"Fitting window restrictors is a simple, inexpensive job that is proven to save lives. Falls from unrestricted or inadequately restricted windows are not uncommon in the healthcare sector – in the years 2008-2011 there were 50 incidents involving falls from windows in the healthcare sector, 12 of which were, sadly, fatal.

"Where there is any risk of vulnerable people falling from windows in a healthcare setting, it is vital that measures are taken to restrict the window opening to no further than 10cms."

HSE guidance on preventing falls from windows is available at http://www.hse.gov.uk/healthservices/falls-windows.htm

Notes to editors

  1. The Health and Safety Executive is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
  2. Section 3(1) of the Health and Safety at Work etc Act 1974 states:"It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."

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