A grandfather died after falling through a hole in his own bathroom that had been left by workers.

Kenneth Armitage landed on the kitchen floor below, in an incident his daughter Suzy said “should never have happened.”

The bathroom in Mr Armitage’s house on Whitestone Drive in Huntington, York had been getting converted into a wet room by the construction company Cooper and Westgate.

The company had removed the room’s floorboards as it accessed pipework, but left an unguarded hole in the floor on 8 February 2019.

The 81-year-old later fell through the hole and was found dead by his son-in-law the following evening on 9 February.

A Health and Safety Executive (HSE) investigation found Cooper and Westgate failed to adequately secure the hole as its employees were not properly trained. The company had also failed to undertake a suitable and sufficient risk assessment, nor a method statement for the work involved.

HSE guidance can be found at: Working at height: A brief guide (hse.gov.uk)

Kenneth’s daughter, Suzy, said: “Our dad, who was sadly taken away from us, was everything to us. He was the kindest person you could ever meet.

“He was a fantastic dad to me, my brother and a loving grandad to all our children.

“I can’t believe he has gone, I keep thinking it’s a horrible nightmare and I will wake up and he’ll be there. Our hearts were broken that day and may never heal. It should have never happened.

“We are all still struggling to come to terms with losing him.”

Cooper and Westgate Co. Ltd, of Navigation Court, Calder Park, Wakefield, West Yorkshire was found guilty of breaching Section 2(1) and Section 3(1) of the Health and Safety at Work etc. Act 1974. The company was fined £150,000 and ordered to pay £50,000 in costs at Leeds Magistrates’ Court on 17 September 2024.

HM inspector of health and safety Yolande Burns-Sleightholme, of HSE, said: “Employers need to fully assess and control the risks from work at height, caused by creating holes in domestic properties and recognise the importance of securing them effectively. They should then pass this knowledge on to their employees through suitable training and guidance.

“This incident could so easily have been avoided had Cooper & Westgate properly assessed the risks, put in place safe working practices and provided the correct training to its employees.”

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary

A body that manages a major forest in East Sussex has been fined after a husband and wife were struck by a tree, with the latter suffering a traumatic brain injury.

Caroline Leafe, 70, was walking along a deer track in Ashdown Forest with her husband, Kenneth, and their dog, Monty, when the pair were hit by a silver birch tree that was being felled on 25 January 2023.

The Conservators of Ashdown Forest, the body that manages Ashdown Forest, had identified that the 12-metre tree was rotting and needed to be cut down.

The tree was located in the corner of Broadstone Car Park on Colemans Hatch Road in Upper Hartfield, East Sussex and surrounded by public footpaths, including the main pathway to the visitor centre.

The tree began to fall after a forest ranger made a sink cut with a chainsaw. As it was falling, the ranger noticed Mr and Mrs Leafe walking on the nearby deer track and attempted to warn them but it was too late.

Mrs Leafe suffered a traumatic brain injury, a fractured collar bone, several fractured ribs and a shoulder dislocation. She spent considerable time in hospital following the incident and continues to undergo physical and cognitive therapy several months later. She also had to surrender her driving licence.

She said in a statement: “I have suffered a loss of independence and Ken has had to do a lot more support to me. I haven’t been able to drive for nearly a year. The head injuries included speech problems and emotional problems.

“There were school children at the forest when we were there and we are relieved that our accident didn’t happen to them. Ken and I hope an incident like this never happens again.”

Mr Leafe suffered cuts and bruising.

A Health and Safety Executive (HSE) investigation found The Conservators of Ashdown Forest failed to identify the risk to members of the public from tree felling. This meant precautions, such as posting warning signs and using barriers and banksmen, were not implemented to prevent members of the public from accessing areas where the tree felling was taking place.

The Conservators of Ashdown Forest pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. The trust was fined £8,000 and ordered to pay £3,589.80 in costs at Brighton Magistrates’ Court on 12 August 2024.

HSE principal inspector Emma Stiles said: “Members of the public should be able to enjoy a walk in a forest without fear of being struck by a tree being felled. The guidance is clear on how to fell trees safely and this means keeping members of the public out of an area around the tree measuring two times the height of the tree.

“This can be achieved by various means including signs, barriers and banksmen. Given the high levels of public access around this tree, all of these precautions should have been taken.”

This prosecution was brought by HSE senior enforcement lawyer Nathan Cook and supported by HSE paralegal officer Imogen Isaac.

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so.  The sentencing guidelines for health and safety offences can be found here.

A local authority has been sentenced after a worker lost his finger while operating a machine.

Adi Soday, a technician at The Forest School in Horsham, lost his right index finger when it was sliced off by a circular bench saw on 13 June 2022.

The 29-year-old, who worked in the design and technology (DT) department, had been operating the saw to cut pieces of wood that were set to be used for a DT lesson.

While pushing one of the sheets of wood through the saw, Mr Soday, who was 27 at the time, felt a pain in his right index finger and immediately turned off the machine.

As he looked down, he saw his finger lying on the bench.

A Health and Safety Executive (HSE) investigation found West Sussex County Council, the local authority in charge of the school, failed to ensure Mr Soday was trained to use the bench circular saw. Mr Soday had used the saw many times but had not been trained on how to use it safely.

West Sussex County Council pleaded guilty to breaching Regulation 9 of the Provision and Use of Work Equipment Regulations 1998. The local authority was fined £16,000, ordered to pay £4,294.60 in costs and a victim surcharge of £190 at Brighton Magistrates’ Court on 3 July 2024.

HSE inspector Russell Beckett said: “Workers must be trained properly when using high risk woodworking such as bench circular saws. This incident could have been prevented had West Sussex County Council provided Mr Soday with proper training.”

This prosecution was brought by HSE enforcement lawyer Iain Jordan and supported by HSE paralegal officer Imogen Isaac.

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

A charitable trust has been fined after a volunteer lost his life during restoration work on the Wilts and Berks Canal.

Peter Konitzer was fatally crushed when a section of a wall collapsed onto him in an excavation at Pewsham locks on 24 August 2016.

The 62-year-old had been inside the excavation removing temporary propping that was supporting the wall when the section collapsed.

Wilts & Berks Canal Trust undertook the restoration work as part of its project to preserve, conserve and improve the route of the Wilts and Berks Canal.

A joint investigation by the Health and Safety Executive (HSE) and Wiltshire Police found Wilts & Berks Canal Trust had failed to ensure the safety of volunteers who were working within the excavation. The temporary propping was inadequate and there was no clear method for the safe installation or removal of props during this renovation work.

The trust routinely used volunteers to assist in work to undertake tasks including clearing rubbish and overgrowth from various canal sites and general gardening type duties but had increasingly used volunteers for light construction works.

Wilts & Berks Canal Trust, of Dauntsey Lock, Chippenham, Wiltshire, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. The trust was fined £30,000 and ordered to pay £10,822 in costs at Swindon Magistrates’ Court on 24 June 2024.

HSE inspector James Lucas said: “This was a tragic and wholly avoidable incident. The situation which led to Peter’s death would not have arisen had the temporary structural works been properly planned and implemented to ensure a suitable safe system of work prior to the incident.

“It is essential that those in control of work of this nature devise safe methods of working and to provide the necessary information, instruction, and training to their workers to ensure their safety.”

This prosecution was brought by HSE enforcement lawyer Iain Jordan and supported by HSE paralegal officer Rebecca Withell.

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. Wilts & Berks Canal Trust will also pay £6,043.16 in compensation.

Kettering General Hospital NHS Foundation Trust has been fined £480,000 after an employee suffered a brain injury after he was found unconscious in a manhole.

The man had been unblocking a drain at the hospital on 1 February 2022 when he was discovered by other members of staff.

He was rescued from the manhole by Northamptonshire Fire and Rescue Service and was treated at hospital for acute sulphate intoxication. This resulted in a traumatic brain injury, and ongoing issues with memory loss and nerve damage.

HSE guidance can be found at: Introduction to working in confined spaces (hse.gov.uk)

A Health and Safety Executive (HSE) investigation found that Kettering General Hospital NHS Foundation Trust failed to identify the manhole as a confined space, and thereafter, failed to properly risk assess the activity. The trust failed to prevent entry of employees into confined spaces at the site – which was custom and practice for a number of years. The trust also failed to identify a safe system of work or method statement for clearing blocked drains and no precautions were identified to reduce the risk of injury.

HSE’s investigation also highlighted that no confined space training was given to members of the estates team and insufficient information and instruction was provided to those involved as to the methods to be adopted, the risks involved and the precautions to be taken, when clearing drains and entering deep drains or manholes.

Kettering General Hospital NHS Foundation Trust, of Rothwell Road, Kettering, Northants, pleaded guilty to breaching Section 2(1) of The Health & Safety at Work etc. Act 1974. The trust was fined £480,000 and ordered to pay £4,286.15 in costs at Wellingborough Magistrates’ Court on 9 January 2024.

The prosecution was brought by HSE enforcement lawyer Samantha Wells.

HSE inspector Heather Campbell said: “This case highlights the dangers of working in confined spaces. The manhole should have been identified as a confined space, and risk assessed accordingly. Safe systems of work for entry into confined spaces should have been in place, such as those outlined in the HSE’s Approved Code of Practice.”

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. www.hse.gov.uk
2. More about the legislation referred to in this case can be found at: www.legislation.gov.uk/
3. HSE news releases are available at http://press.hse.gov.uk

A company and its director have been sentenced after an employee fell from height and suffered serious injuries.

Andrew Smith fractured his left femur, left elbow, left arm and pelvis after falling approximately three metres off a ladder on 28 July 2021.

He had been working for Profascias Ltd at Park Lane Primary School in Tilehurst, Reading.

The company had been hired to replace guttering and supply fascia boards and soffits at the infant school.

The ladder Mr Smith had been working from against the school wall slipped, causing the 53-year-old to fall to the ground.

He spent 16 days in hospital as a result of his injuries and later underwent surgery to add a bolt to his hip and metal plate to his arm.

A Health and Safety Executive (HSE) investigation found there had been insufficient planning of the work at height by Profascias Ltd and its director, John Nolan. A safe platform from which to work, such as a properly erected scaffold, should have been provided as workers needed both hands to carry out the work and could not therefore work safely from a ladder. Ladders should only be used for access or, where it is not reasonably practicable to provide safer working platforms, for short-term work of up to 30 minutes where workers can normally maintain three points of contact.

HSE guidance can be found at: Work at height – HSE

Profascias Ltd, of Sandy Lane, Pamber Heath, Tadley, Hampshire, pleaded guilty to breaching Section 4(1) of the Work at Height Regulations 2005. The company was fined £6,000 and ordered to pay £2,000 in costs at Slough Magistrates’ Court on 18 December 2023.

Imposing the sentence, District Judge Goozee remarked: “Because of the financial penalty, the company may end up being wound up completely; but that is a consequence of the conviction.”

John Nolan, of Sandy Lane, Pamber Heath, Tadley, Hampshire, pleaded guilty to breaching Section 4(1) of the Work at Height Regulations 2005 by virtue of Section 37(1) of the Health and Safety at Work etc. Act 1974. He was handed a 12-month community order where he must undertake 180 hours of unpaid work and ordered to pay £1,000 in costs at Slough Magistrates’ Court on 18 December 2023.

HSE inspector Rachael Newman said: “This worker’s injuries were serious. This incident could have been avoided through the selection of suitable work equipment to prevent persons from falling.

“Falls from height remain one of the most common causes of work-related fatalities and injuries in this country and the risks associated with working at height are well known.”

This HSE prosecution was brought by HSE enforcement lawyer Jon Mack and supported by HSE paralegal officer Cristina Alcov.

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

One of the largest health boards in Wales has been fined £200,000 after a patient died in its care.

Llandudno Magistrates’ Court heard that 46-year-old Dawn Owen was found unconscious at the Hergest Unit – a secure mental health unit – at Ysbyty Gwynedd in Bangor on 20 April 2021.

Dawn’s family have called on Betsi Cadwaladr University Health Board to act on the findings of a Health and Safety Executive (HSE) investigation, calling her death ‘wholly avoidable’ and ‘completely unnecessary’.

“Staff complacency at all levels contributed in this case, as well as numerous policy breaches and issues between staff and management,” they said.

“We have been tragically let down by the Hergest Unit, who we believed, were providing a safe place for Dawn and the care that she urgently needed.”

The HSE investigation found no risk assessment had been carried out when she was admitted and due to communication failure on transfer to the ward, staff had wrongly relied on an assessment carried out for a previous admission a year earlier. This failure resulted in Dawn’s high risk of self-harm being tragically missed.

Staff also failed to place her in an anti-ligature bed and had de-escalated the completion of regular monitoring checks. Dawn was also provided with a dressing gown and belt, of which the belt was later used as a ligature.

There were several missed opportunities during the course of the admission, where Dawn had expressed the desire to self-harm. This did not trigger any review of the care and management of the patient.

“Dawn was a highly vulnerable person and had been battling her demons and addictions for many years,” the family went on to say.

“She was a bright, happy person who always had a positive attitude. She had a heart of gold and would always help others in need – she would give away her last penny to do so.

“Betsi Cadwaladr must now act on the findings of this investigation and keep vulnerable patients safe at the unit.

“We hope as a family that Dawn may now rest in peace – her battles with mental health are now over.

“We as a family would like to thank the Coroner and HSE for their diligence in ensuring there was a thorough investigation into Dawn’s untimely death.”

Betsi Cadwaladr University Health Board have pleaded guilty to breaching Section 3 (1) of the Health and Safety at work Act 1974 and have been fined £200,000 and ordered to pay costs of £13,174 at Llandudno Magistrates’ Court on 18 December 2023.

Speaking after the case, HSE inspector Sarah Baldwin-Jones said: “This incident could so easily have been avoided had a thorough risk assessment been carried out on admission, identifying in this case, the change in Dawn’s condition and risk of self-harm.

“Where a patient presents with a risk of self-harm, there is a requirement upon a health board to manage the patient’s safety, to avoid incidents like this. Devices such as reduced ligature beds and removing ligature anchor points and ligatures in the ward environment, can assist staff manage these risks. Importantly, the health board should have trained staff in managing this risk in patients considering self-harm.

“This would enable staff to identify the trigger points and take appropriate actions. The health board also failed to monitor the management of patients, so that any patient emotional or behavioural changes can be identified and managed.

“Health Boards and Trusts should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards. Our thoughts remain with Dawn’s family and friends.”

This prosecution was led by HSE enforcement lawyer Samantha Wells.

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

• Company fined for failings in two separate incidents.
• Two workers seriously injured after falling through roofs in separate incidents.
• Business partner at scaffolding firm sentenced following incident in Swansea.

A roofing company has been fined a total of £881,000 after two workers were seriously injured during two separate incidents.

Billy Hewitt, a worker at Mitie Tilley Roofing Limited, fractured his pelvis after falling through a factory roof in Newcastle. Meanwhile, a 24-year-old labourer employed by RM Scaffolding broke his femur after falling through the roof of a building in Swansea while working on a project run by Mitie Tilley Roofing Limited.

The Health and Safety Executive (HSE) investigated both incidents and prosecuted Mitie Tilley Roofing Limited. Paul Robinson, a business partner at RM Scaffolding, was also prosecuted by HSE following the incident in Swansea.

On 11 November 2019, Billy Hewitt, 60, fractured his pelvis, left wrist and eye socket after falling through the roof of a factory in Throckley, Newcastle upon Tyne.

He had been replacing a skylight when he fell and landed on the concrete floor seven metres below. Billy was in hospital for three weeks after the incident.

Billy, who is from Whickham, said: “You don’t go to work in the morning and expect to end up in intensive care but that’s what happened to me. It’s been four years since my accident and I don’t know really do anything with my days. I really miss work. I was a roofer for 40 years but this accident changed everything because I still can’t work. I used to earn a good wage, but now I’m classed as 51% disabled and I rely entirely on benefits.”

The HSE investigation found Mitie Tilley Roofing Limited failed to properly plan and carry out the work to replace the skylight. The work at height had not been thoroughly assessed as a standalone piece of work. The investigation also found that safety nets were in place on other sections of the roof but not directly underneath the skylight where the accident happened.

HSE guidance can be found at: Work at height – HSE

On 3 June 2019, a scaffold labourer, employed by RM Scaffolding, was crossing a fragile roof when he fell through a skylight at a unit at Plasmarl Industrial Estate in Swansea. The 24-year-old landed on his back approximately 20 feet on the floor below. He fractured his femur and suffered a blood clot in one of his main arteries, which required long-term medication.

HSE found that Mitie Tilley Roofing Limited, the principal contractor for the project, failed to plan, manage and monitor the work undertaken by RM Scaffolding, the sub-contractor, to prevent unsafe work practices being used. Paul Robinson, a business partner at RM Scaffolding, failed to plan the work properly and ensure staff had appropriate skills, knowledge and experience. Robinson also failed to provide appropriate fall protection on the roof.

Following the incident on 11 November 2019, Mitie Tilley Roofing Limited, of London Bridge Street, London, was found guilty to breaching Section 2(1) of the Health and Safety at Work etc. Act 1974 and breaching Regulation 4(1) of the Work at Height Regulations 2005, following a two-week trial in April 2023. Following a three-day sentencing hearing at Newcastle Crown Court on 6 December 2023, Mitie Tilley Roofing Limited was fined £575,000 and ordered to pay £84,940.08 in costs.

Following the incident on 3 June 2019:

• Mitie Tilley Roofing Limited pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. Following a three-day sentencing hearing at Newcastle Crown Court on 6 December 2023, Mitie Tilley Roofing Limited was fined £306,000 and ordered to pay £27,410.63 in costs.

• Paul Robinson, of Laburnam Way, Penarth, Vale of Glamorgan, pleaded guilty to breaching Regulation 4(1) of the Work at Height Regulations 2005. At Newcastle Crown Court, on 5 December 2023, he was sentenced to 120 hours of unpaid community service, to be served within 12 months. He was also ordered to pay £20,428.73 in costs.

HSE principal inspector John Heslop said: “Too many workers are injured or die every year as a result of falling through fragile rooflights without adequate fall prevention or protection measures in place.

“These were both shocking incidents, which had a lasting impact on those who were injured.

“The law is clear about the measures needed to ensure safety when working on fragile roofs and there is a wide range of guidance available from HSE and the Construction industry on correct ways of working. HSE will not hesitate to take action against employers who do not do all that they should to keep people safe.”

Notes to editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

A production company has been fined after a stunt performer was injured during the filming of Fast and Furious 9: The Fast Saga.

Joe Watts, from Surrey, sustained life-changing injuries after he fell approximately 25 feet at Warner Bros. studios in Leavesden, Hertfordshire on 22 July 2019.

He had been filming a fight scene for the action movie.

Mr Watts fell 25 feet onto the concrete floor below when the line on his stunt vest became detached.

As a result of his fall, Mr Watts suffered a fractured skull and a severe traumatic brain injury, which has resulted in permanent impairment and disability.

A Health and Safety Executive (HSE) investigation found several failings by FF9 Pictures Limited. FF9 Pictures Limited’s risk assessment failed to address the potential issue of a rope snap or a link failure, there was no system for double checking that the link had been properly engaged and tightened. There was also no system for checking the link for signs of deformation or stretching between takes, the manufacturer’s website stated that the link used was forbidden for use as PPE and shock loading should be avoided. On top of that, six-monthly inspections of harnesses were required but Mr Watts’ harness had not been inspected in the last six months and FF9 Pictures Limited did not extend the crash matting needed to mitigate the consequences of an unintended fall following changes to the set and the sequence of the stunt.

FF9 Pictures Limited, of St. Giles High Street, London, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. The company was fined £800,000 and ordered to pay £14,752.85 in costs at Luton Magistrates’ Court on 24 November 2023.

HSE inspector Roxanne Barker said: “Mr Watts’ injuries were life-changing and he could have easily been killed. In stunt work, it is not about preventing a fall but minimising the risk of an injury.”

This prosecution was brought by HSE enforcement lawyer Rebecca Schwartz and supported by HSE paralegal officer Gabrielle O’Sullivan.

Sentencing, district judge Talwinder Buttar stated Mr Watts is fortunate to be alive and added that she was astonished that the crash matting was not adequate.

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. hse.gov.uk
2. More about the legislation referred to in this case can be found at: legislation.gov.uk/
3. HSE news releases are available at http://press.hse.gov.uk

The company that runs The Priory Hospital has been fined for failing to ensure the safety of patients on the hospital’s Emerald Ward following the death of 21-year-old Francesca Whyatt.

Francesca, from Knutsford in Cheshire, was found unconscious at The Priory Hospital in Roehampton, London. She died three days later.

Priory Healthcare has been fined £140,000 after an investigation by the Health and Safety Executive (HSE).

Francesca died on 28 September 2013. She had been transferred from a local hospital to the Emerald Ward, a specialist unit at The Priory Hospital, in March 2013.

She was found unconscious in a patient lounge on the top floor of the hospital on 25 September.

Francesca had managed to make her way to the lounge as the hospital responded to an incident involving other patients and used the tights that she was wearing as a ligature.

An investigation by HSE concluded Priory Healthcare Limited failed to ensure the provision of in-patient psychiatric treatment was carried out in such a way that patients were not exposed to risks to their health and safety.

Daniel Whyatt, Francesca’s brother, said his sister was a “truly selfless [and] special individual.”

Daniel said: “The tragic and untimely death of our beloved sister has had a profound impact, and has repercussions well beyond those conceivable to anyone outside of our little family unit. It has invariably ruined all of our lives, and has muddied the precious memories we have of Francesca.

“It is a strange thing to note that it is just as difficult to write her name as it is to speak it, all these years later it is still so raw. We should be able to talk about her fondly, with a smile… instead every mention of her is done so in anger and rage and it feels like being stabbed in the heart.

“It is extremely overwhelming. Francesca had a proclivity for helping everyone she met and changed their lives in positive and meaningful ways, often at her own expense. She was a truly selfless, special and unique individual.”

Priory Healthcare Limited, of Hammersmith Road, Hammersmith, London, pleaded guilty to failing to discharge a duty under Section 3(1) Health and Safety at Work etc. Act 1974. The company was fined £140,000 at Southwark Crown Court on 14 November 2023. Costs will be decided at a later date.

Paul Hems, HSE’s head of operations for London, said: “This incredibly sad case highlights the need for suitable and sufficient systems to be put in place to monitor patients.

“Employers should be aware that HSE will hold to account those who do not comply with health and safety legislation. It should also be noted that similar incidents which have taken place after April 2015 will be enforced by the Care Quality Commission (CQC).”

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. Following the Mid Staffordshire NHS Foundation Trust Public Inquiry and the publication of the Francis Report, the Care Quality Commission (CQC) was given powers to carry out criminal investigations and bring prosecutions. These took effect in April 2015. Since that time, in England, the CQC has been the regulator for patient health and safety matters, with HSE regulating health and safety for workers and members of the public. A revised memorandum of understanding reflecting these changes and setting out areas of responsibility was agreed by the two organisations which is available on HSE’s website. MoU between the Care Quality Commission (CQC) and HSE