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.

A frozen food company has been fined £700,000 after an employee lost two of his fingers following an incident at the firm’s premises in Lincolnshire.

Tom Matthews, from Grantham, now champions health and safety in his current job at a different company, warning others to avoid his misfortune.

He had been working a night shift at McCain Foods’ site in Easton on 2 September 2019 when he suffered serious injuries to his left hand.

While cleaning the company’s batter system machinery, the 33-year-old had attempted to remove string dangling from a chute when his left hand was drawn in and contacted the machine’s rotary valve.

The index and middle finger were later amputated as a result of the incident.

Tom Matthews, a father-of-two said: “The last four years have been hard and an ongoing struggle both physically and mentally.

“I still have circulation problems in my left hand following the incident that should never have happened.

“While I’m currently working, my new role is with the health and safety team at a different company as I want to use my story as an example to others and make sure something like this doesn’t happen again.”

A Health and Safety Executive (HSE) investigation found that McCain Foods had failed to provide appropriate guarding to prevent access to the dangerous parts of machinery, namely the rotary valve. It had not conducted an adequate risk assessment of the batter machine and had not provided employees with adequate health and safety training or supervision.

HSE guidance can be found at: Provision and Use of Work Equipment Regulations 1998 (PUWER) (hse.gov.uk)

McCain Foods (G.B.) Limited, of Havers Hill, Eastfield, Scarborough, North Yorkshire, pleaded guilty to breaching Section 2(1) of the Health & Safety at Work etc. Act 1974 and Section 11(1) of Provision and Use of Work Equipment Regulations 1998 (PUWER). The company was fined £700,000 and ordered to pay £6,508.51 in costs at Lincoln Magistrates’ Court on 22 November 2023.

HSE inspector Muir Finlay said: “This incident could so easily have been avoided had the company taken simple steps to guard dangerous parts of machinery and provide employees with suitable training and supervision.

“Companies and individuals should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

This prosecution was led by HSE enforcement lawyer Jonathan Bambro and supported by Rubina Abdul-Karim.

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.

The mother of a man who was killed when the forklift truck he was driving overturned says she still feels angry as he ‘simply went to work and didn’t come home.’

Jamie Anderson was killed on 4 June 2019, when the forklift truck he was operating overturned at a depot in Newark.

The 35-year-old father of one, was found in the car park trapped under the roll cage of the vehicle. He had been using a counterbalance forklift truck to move waste material when it clipped a kerbstone at the edge of the roadway and overturned. He was not wearing a seatbelt. 

His mum Sarah Anderson, a care assistant from Newark, said: “No mother should lose a child and for Jamie’s son Harley he has lost a loving father.

“As a family we have gone through all emotions, and I still feel angry as Jamie simply went to work and didn’t come home. This should not have happened.

“He was a happy-go-lucky boy and would do anything for anyone. It’s the everyday things that remind me of him and I miss his smile and blue eyes. He’s missed so much.”

An investigation by the Health and Safety Executive (HSE) found that The Barcode Warehouse Ltd failed to enforce the use of seatbelts by forklift truck operators. They should have properly risk assessed the use of forklift trucks on their premises and enforced the use of seatbelts. Instead, it was left to individuals to choose whether to wear a seatbelt or not.

HSE has guidance available on managing forklift trucks.

At Nottingham Magistrates’ Court on 8 November the Barcode Warehouse Ltd of Telford Drive, Newark pleaded guilty to breaching Section 2(1) of the Health & Safety at Work Act 1974.  They were fined £500,000 and agreed to pay costs of £7,039.55.

Speaking after the hearing HSE inspector, Tim Nicholson said: “This tragic incident led to the avoidable death of a young man. Jamie’s death could easily have been prevented if his employer had acted to identify and manage the risks involved and enforced the use of seatbelts by forklift truck operators.”

This HSE prosecution was supported by HSE lawyers Nathan Cook and Jonathan Bambro, and Paralegal Officer Rubina Abdul-Karim.

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 commercial printing company has been fined £100,000 after an employee’s hand was crushed by a laminating machine.

The man had been working for Celloglas Limited at the firm’s site at Cross Green Industrial Estate in Leeds.

He was attempting to fix a laminating machine on 25 November 2020 when his right hand was drawn into the device and crushed between two rollers. The worker, who was 31 at the time, realised the machine had broken while he was feeding the device with paper.

The incident led to the man’s right hand sustaining soft tissue crush injures as well as nerve damage and contact burns to his right wrist. The injuries to his hand meant the man could not drive for seven months following the incident and also led to him suffering with anxiety and PTSD.

A Health and Safety Executive (HSE) investigation into the incident found the laminating machine was not adequately guarded and that the company failed to review existing risk assessments for the machine which required the production of a safe system of work.

HSE guidance can be found at: Managing risks and risk assessment at work – Overview -HSE

Celloglas Ltd, of Exeter Way, Theale Commercial Estate, Theale, Reading, pleaded guilty to breaching Section 2 (1) of the Health & Safety at Work etc Act 1974. The company was fined £100,000 and ordered to pay £5,165.09 in costs at Leeds Magistrates’ Court on 30 August 2023.

HSE inspector Darian Dundas commented: “A review of existing risk assessments for the machine should have identified that a safe system of work was required to keep operatives safe from harm. Had such a review taken place then this incident could so easily have been avoided.”

This HSE prosecution was supported by HSE enforcement lawyer Gemma Zakrzewski.

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 plant hire company has been fined for leaving workers at risk of a fall from height and failing to provide minimum welfare facilities.

Blackpool Magistrates’ Court heard how, on 17 November 2020, Ruttle Plant (Birmingham) Ltd was in the process of building a new aggregate recycling facility at their site at Common Bank Lane, Chorley. Part of the work included the provision of cladding to the roof, which was carried out using a cherry picker. However, as some areas of the roof were difficult to reach, employees had to step onto the roof where no edge protection had been provided, putting them at risk of a 30ft fall. In addition, workers had been on site for some considerable time without the minimum required welfare facilities being available. This included facilities for hand washing during the height of the Covid pandemic.

An investigation by the Health and Safety Executive (HSE) found that the workers had been left unsupervised by site management, there had been no method statement to follow when they climbed onto the roof and there were no preventative measures in place to prevent the risk of a fall from height. Workers were also expected to drive to the company’s head office along an unadopted roadway more than five minutes’ drive away to use the toilet, despite there being ample room on the site for facilities.

Ruttle Plant Hire (Birmingham) Ltd of Lancaster House, Ackhurst Road, Chorley, Lancashire pleaded guilty to breaches of Regulation 13(4)(c) of the Construction (Design and Management) Regulations 2015, and Regulation 4(1) of The Work at Height Regulations 2005. The company was fined £66,667 and ordered to pay costs of £1,847.

Speaking after the hearing, HSE inspector Christine McGlynn said: “Had a worker fallen off the roof edge, it could have been fatal. Employers should ensure that workers are not left to carry out high risk roof work without supervision.

“Work at height and roof work should only be carried out by trained workers, who are being robustly monitored, following proper planning, risk assessment and using suitable equipment. The minimum standards for welfare must also be met.”

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: Construction- Roof work industry health and safety 
3. HSE news releases are available at http://press.hse.gov.uk