In November 2012, at Priory Ticehurst Hospital the patient was found with a ligature around her neck in her room and suffered irreparable brain damage and failure of multiple organs, so a decision was taken to withdraw life support the following day.
An investigation by the Health and Safety Executive (HSE), which began in 2016 following the coroner’s inquest, found Priory Healthcare Ltd had failed to identify or put in place control measures that would have better managed ligature risks.
Priory Healthcare Ltd plead guilty to a breach under Section 3 (1) of the Health and Safety at Work etc. Act 1974. The company has been fined £300,000 and ordered to pay costs of £65,801.38.
The company’s main failings were as follows:
Failure to carry out a suitable and sufficient risk assessment relating to the presence of ligature points and ligatures;
Failure to identify the control measures necessary to reduce ligature risks;
Failure to consider relevant industry and NHS guidance to determine the correct fixtures and fittings for units where patients were at high risk of self-harm and suicide;
Failure to ensure an adequate review was carried out of the systems and control measures relating to ligature risks;
Failure to ensure all staff working were trained and their work practices appropriately monitored with respect to life support techniques.