06 April 2021
The States Employment Board (SEB) was fined £80,000 and ordered to pay costs of £5,000 by the Royal Court on 26 March 2021 after pleading guilty to a breach of Article 5 of the Health and Safety at Work (Jersey) Law 1989.
The prosecution followed an incident that occurred on 8 May 2020 when a patient that had been voluntarily admitted to the Acute Admission Unit at Orchard House. As a place of safety, she was able to access the roof and jump from a two-storey height, suffering serious physical injuries. The patient had a diagnosed risk of self-harm, suicidal ideation and had previously gone to a place of height with the intention of hurting herself.
Investigation by the Health and Safety Inspectorate identified that on the day in question she was able to leave the ward environment and access the garden, unsupervised, through a door that should have been locked but was in fact propped open with a plant pot. Once in the garden, the patient was able to climb a fence and gain access to the roof of the building.
The court heard evidence that aggravated the offence as warnings and near-misses had been ignored. In 2018 the Health and Social Services (HSS) department was served with an Improvement Notice by the Health and Safety Inspectorate requiring an environmental risk assessment be carried out for Orchard House. HSS’s subsequent risk assessment identified that there was a risk of patients accessing roofs from the garden and recommended an anti-climb fence be erected. The action plan accompanying the risk assessment indicated this was supposed to be completed by October 2018, but it was never done.
The Health and Safety Inspectorate investigation also identified at least two other incidents since 2018 when patients had climbed over the fence in the garden to abscond and a further two occasions when patients had accessed the roof.
Despite these near misses a situation was allowed to exist, until this serious incident, before positive action was taken to prevent patients accessing the roof of the unit.
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