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.

A construction company has been fined following the death of a worker.

Gary Webster lost his life two days after drowning in the River Aire on 30 October 2017.

Mr Webster and another worker had been on a boat removing debris at the bottom of the weir gates at Knostrop Weir when their boat capsized. The boat had been pulled into turbulent water, caused by the considerable flow of water flowing over the top of the weir.

The 60-year-old was repeatedly pulled under the water and was eventually recovered by a diver 14 minutes later. The other worker managed to swim to safety.

Mr Webster was pronounced dead on 1 November 2017 at Leeds General Infirmary.

A Health and Safety Executive (HSE) investigation found BAM Nuttall Ltd had several operatives who were trained and authorised to control the weir gates so that the flow of the water could be slowed down. This would have allowed the debris to float away or be reached safely by boat. However, the company failed to carry out this task.

BAM Nuttall Limited, of Knoll Road, Camberley, Surrey, pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc. Act 1974. The company was fined £2.345 million and ordered to pay £25,770.48 in costs at Leeds Magistrates’ Court on 12 June 2024.

HSE inspector Jayne Towey said: “BAM Nuttall Ltd failed to plan the work. It failed to carry out any assessment of the risks involved with the task. It failed to have any regard to the recognised hierarchy of controls to reduce the risk associated with removing debris from the water. It failed to ensure that suitable safety measures were in place and failed to put in place a safe system of work.

“This incident could so easily have been avoided by simply carrying out correct control measures and safe working practices.”

This prosecution was brought by HSE enforcement lawyer Jonathan Bambro and supported by HSE paralegal officer Sarah Thomas.

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.

Openreach Limited has been fined £1.34 million after an engineer died whilst trying to repair a telephone line.

Alun Owen, from Bethesda, died after he slipped and fell into the River Aber in Abergwyngregyn and was swept away on 6 October 2020.

The 32-year-old has been described by his family as a ‘loving and selfless character’.

An investigation by the Health and Safety Executive (HSE) and North Wales Police, found that a number of Openreach engineers had been attempting to repair the telephone lines, which ran across the river, over a period of two months. They had been working both near and in the river.  At the time of the incident, there had been flooding in the area which meant the river was much higher and faster flowing than usual.

Mr Owen entered the water and made his way to an island in the middle of the river in order to try and throw a new telephone cable across to the other side by taping it to a hammer and then throwing the hammer. Whilst attempting to cross the remaining section of the river, he slipped in a deeper part and the force of the river swept him away.

The investigation found that there was no safe system of work in place for work on or near water, nor had Mr Owen – and others working by the river – received training, information or instruction on safe working on or near water.

A statement from Mr Owen’s family said: “The genuine love and affection shown to us since the tragedy that unfolded on the 6 October 2020 is a real testimony to Al and how everyone just loved his friendly, loving and selfless character.

“Although it’s sometimes difficult to see beyond the sorrow, we will keep his memory alive through reminiscing those many precious moments he had in his love-filled life.”

Openreach Limited pleaded guilty to breaching Section 2 (1) of the Health and Safety at work etc. Act 1974. The company was fined £1.34 million and ordered to pay costs of £15,858.35 at Llandudno Magistrates’ Court on 5 June 2024.

Speaking after the case, HSE inspector Christina Roberts said: “This was a tragic incident that resulted in the death of a much loved young man.

“Mr Owen’s family, friends and colleagues have always remained in our thoughts.

“His death would have been preventable had an effective system for working on or near water been in place.

“Mr Owen should not have been put in the unsafe working situation. Companies should learn the lessons from this incident if they have staff who may work on or near water and be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

North Wales Police Detective Chief Inspector Andy Gibson said: “Our thoughts remain with Alun’s family at this difficult time.

“North Wales Police worked closely with HSE and whilst it was a protracted and lengthy investigation, it was critical that any failings were identified and acted upon.”

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

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 legislationreferred to in this case is available.
3. Further details on the latest HSE news releasesis available.

Tata Chemicals Europe Limited has been fined after a young father died following an incident while erecting a scaffold tower in a chemical plant in Northwich.

Michael Densmore, from Halewood in Merseyside, died following complications to the wound he sustained after his right foot slipped into a trough containing a liquid chemical calcium hydroxide – more commonly known as ‘milk of lime’ – causing chemical and thermal burns.

The 37-year-old father-of-four was one of a number of scaffolders employed by Altrad NSG to erect scaffolding at Tata’s Lostock Hall site.

On 30 November 2016, during the course of this work, Mr Densmore stepped over a trough which contained milk of lime – which had been heated to approximately 90 degrees centigrade. His right foot slipped on an unfastened lid covering the trough, resulting in him sustaining chemical and thermal burns to his foot and ankle.

He was airlifted to Whiston Hospital burns unit, where he received specialist treatment and underwent surgery on 8 December and was discharged just over a week later.  However, on 3 January 2017, while at home, he suffered a haemorrhage to his right foot and was taken to hospital following a 999 call, but tragically died.

In a statement issued by his family, Micheal was described as ‘a loving and amazing role model’ to his sons and two nieces.

“Our lives fell apart and have not been the same since that terrible day,” they said. “Nobody should have to lose someone they love, due to an accident that happened at work.

“A mother should never have to give CPR to her own son, and a partner, should never have to tell their children that their dad will not be coming home.

“Michael has missed so many life events in the past seven years, including missing his nieces having their own babies, his eldest son giving him a grandson, his youngest boys communions, to name just a few.

“What hurts us the most is the fact that he will never be able to complete all the plans he had for life, including marrying his Helen.

“The trauma, we have all suffered as a family, cannot truly be put into words. We were once a small happy close-knit family, who all lived life to the full, with Michael being the leader and now we just about get through each day.”

The Health and Safety Executive (HSE) investigation found there was no permit in place for hazardous work in a live chemical plant.  Little proper thought had been given to the risks involved by those responsible for ensuring staff safety. As far as the scaffolding team was concerned, there was no clearly understood plan to address these risks. Mr Densmore had only received a brief induction when he started work on the site some months before.  Crucially, he had not been warned that there would be chemical product flowing through the plant and that the lids to the trough had not been properly sealed.  Tata employees had been seen working on or near the troughs and there were no visible warning signs in place.

It also found that there had been previous prosecutions of Tata Chemicals Europe relating to health & safety failures at Lostock Hall and nearby Winnington Lane.

Tata Chemicals Europe Limited, of Winnington Lane, Northwich, Cheshire pleaded guilty to breaching Section 3(1) of the Health and Safety at work etc. Act 1974. The company was fined £1.125 million and ordered to pay £60,603.54 in costs at Chester Crown Court on 5 June 2024.

Speaking after the case, HSE inspector Matt Lea said: “This tragic death could have been preventable had Michael Densmore and his colleagues been managed under a robust permit to work system for working in a live chemical plant containing corrosive chemicals which had been heated almost to boiling point.

“Michael should not have been put in this unsafe working situation and should have been warned about the dangers of stepping over the troughs and that they were still in operation.

“Companies should learn the lessons from this incident if they have staff or contractors working in a similar environment and be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

This prosecution was brought by HSE enforcement lawyer Chloe Ward and supported by HSE paralegal officer Sarah Thomas.

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 legislationreferred to in this case is available.
3. Further details on the latest HSE news releasesis available.

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.