Health board fined £200k for mental health failings that led to patient's death

A health board has been fined £200,000 after a woman killed herself on one of its mental health wards. 

Dawn Owen, 46, attached a dressing gown cord to ligature points on her bed in April 2021 at the Hergest unit of Ysbyty Gwynedd, Bangor. 

Llandudno Magistrates' Court heard that she had not been properly assessed and so was put in a bed with ligature points and given the dressing gown. 

The court was told that Ms Owen called an ambulance after trying to kill herself at home and was admitted to the Aneurin ward at the Hergest unit.

But even though Betsi Cadwaladr health board’s own rules said new patients should undergo a risk assessment on arrival, staff did not consider whether she was likely to try to take her life again. Instead, they used an old risk assessment from when Ms Owen had been a patient there the previous year. 

They gave her an inappropriate bed, in a place which was not directly visible from the nursing station, and a dressing gown with a cord belt. Even though she told staff she was thinking of taking her own life, the risk assessment was not changed during the days she was there and checks on her were reduced. 

The health board pleaded guilty to a charge under the Health and Safety at Work Act of failing to ensure the safety of patients in its care. 

Representing the Health and Safety Executive (HSE), David James, told the court it "was not an isolated incident.” 

He said: "There was an ongoing failure in the system, and it applied to all patients - people who entered the ward at their most vulnerable. It's not the case that the health board had no systems in place to protect people. They were not adhered to at all."

In a statement read in court, Ms Owen's father, Alan Owen, described how his daughter's death had "shattered family life" and "left an unfillable void." 

He said: "She had a heart of gold and would give away her last pound to help someone. She was a loving daughter and sister. We are angry about the failings of the NHS, as it appears nothing has changed, and lessons have not been learned." 

But Nigel Fryer, representing the health board, said things had changed.  He said: "I offer my condolences, and above all an apology. Anyone who works in the NHS wants to help people, and change has been implemented, change is ongoing.  The culture now is one of determination to make sure people like Dawn are not let down in the future."

District judge, Gwyn Jones, said "there was a lack of understanding that risk is not static, it goes up and down. There was an inconsistent application of policies, and a failure to share and disseminate information.

"But it is quite clear there has been a change in mindset, though it is also clear that there is some way to go.  While any fine must have a real and economic impact, I can't ignore when imposing a fine that it will impact on the service the health board provides to the public."