21 hours Ago
BETSI Cadwaladr University Health Board has been fined £250,000 following failures relating to patient falls in its hospitals. Three elderly patients sustained falls in 2022 and 2023, and they all subsequently died - the cause of death of two of them was identified as being as a direct result of falling. Richard Hughes, 84, and Gwilym Williams, 74, fell at Ysbyty Gwynedd in Bangor in January and June 2022 respectively.
Nancy Read, who was 93, fell at Wrexham Maelor Hospital in January 2023. The health board was initially investigated by the Health and Safety Executive (HSE) following two other patient falls in 2020, one of which resulted in fatal injuries. As a result, HSE took enforcement action against the health board that required it to implement an effective patient fall management system, including: The enforcement action also required the health board to review the patient falls policy and to ensure the entire system worked effectively.
A follow-on inspection made in November 2021 identified that Betsi Cadwaladr was still not managing patient falls; this resulted in a further action being taken. But during the next two years, the three patients died and the health board had not implemented a system to identify and manage patient falls quickly, or provide staff with updated training. Betsi Cadwaladr pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work Act 1974, and was fined £250,000 and ordered to pay costs of £11,766.
Speaking after the case, HSE inspector Sarah Baldwin-Jones said “This is the second time this health board has been prosecuted in less than 18 months. “These incidents could so easily have been avoided had Betsi Cadwaladr University Health Board followed their own adult falls policy. “Effective management of patient falls includes thorough risk assessment, effective communication on risk management, monitoring and re-evaluation should the patient condition deteriorate.
“Staff and agency workers need to follow the same training pathway, ensuring those responsible for falls management have the skills to make appropriate decisions. “Unfortunately, these actions were not always followed and as a result some patients suffered falls, which resulted in two preventable deaths.”.
