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NHS Foundation Trust fined over patient death

22 June 2017

Surrey and Borders Partnership NHS Foundation Trust has been fined for health and safety failings after a patient fell to his death.

Adam Withers, 20, from Epsom had been detained as an in-patient at Epsom Hospital when the incident occurred on 9 May 2014.

Guildford Crown Court heard how Mr Withers was in the courtyard with his mother while being observed by a nurse from inside the ward when he started to climb up onto the conservatory roof.

The nurse immediately ran into the courtyard but was unable to prevent him climbing over the roof. He then climbed up a 130-foot industrial chimney and after attempts to talk him down failed, he fell and sustained fatal injuries.

An investigation by the Health and Safety Executive (HSE) found a series of failures to ensure the risk associated with absconding was properly managed. There was insufficient communication between employees and inadequate systems to ensure the risk identified were addressed and remedied.

Speaking after the hearing, HSE Inspector Russell Beckett said: “The Trust failed to make appropriate changes following previous incidents. Had the Trust carried out a suitable assessment and made the appropriate changes they would not have allowed a vulnerable person the opportunity to end his life.”

Surrey and Borders partnership NHS Foundation Trust of Mole Business Park, Randalls Road, Leatherhead, pleaded guilty to breaching Section 3(1) of The Health and Safety at Work etc. Act 1974 and was fined £300,000 and ordered to pay costs of £16,769.00.

Notes to Editors:

  1. The Health and Safety Executive (HSE) 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.


  1. The HSE has a legal duty to make inquiries about all allegations or complaints made to it, initially to determine whether there are grounds to formally investigate possible breaches of health and safety regulations.


  1. Until 1 April 2015, allegations of unsafe working practices at medical establishments, unrelated to clinical matters, could be referred to HSE. After this date, the Care Quality Commission (CQC) became the lead regulator, including investigating potential breaches of health and safety regulations.


  1. Since 1 April 2015, this HSE investigation was conducted as a historic inquiry, as the HSE was the responsible regulator at the time these offences were committed.


  1. Further information about how the HSE decides on whether to launch a formal investigation can be found at and


6.           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.” Further information about the legislation applied in this case can be found at

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