Powys Local Health Board (the board) has been fined £30,000, plus £46,849 prosecution costs, after a vulnerable patient in its care hanged herself. The board admitted breaching health and safety legislation because of a failure to deal with the risks posed by ligature points. The court was told that as far back as 2001, when under the management of the previous NHS trust, warnings, bulletins, audits and memos had been circulated in respect of the risk of ligature points of the unit, built in 1999 when ordinary curtain tracks were installed.
Sylvan Money, 26, an artist from Presteigne, was admitted to the acute mental illness (AMI) unit at Bronllys Hospital, near Brecon, in January 2004. Within days she had taken her own life, using a dressing gown cord to hang herself from a curtain rail.
Fining the board, Judge Eleri Rees said: “When Sylvan Money was admitted she was admitted as a suicide risk and she succeeded by hanging herself from a ligature point in the ward.” She went on to say: “It is clear from everything I have heard that there was a history of systematic management failures that were inherited from the previous trust.”
Judge Rees told the court that the previous trust had tried to address problems and had even reached the stage of costings, but the matter had “fallen” by the wayside in light of other pressing issues. She said that at the end of the day, a prepared risk assessment had become overlooked and forgotten because of other pressing issues taking precedence.
This case serves as a reminder that there is little, if any, justification for ligature points not being addressed by NHS bodies where they may pose a risk to vulnerable patients. This also applies to other health and safety risks such as falls from windows.