Report details failings over Swindon patient's fall from ward roof

NHS bosses knew that a low roof at a Swindon mental health unit was a safety risk before a patient slipped off it 11 hours after scaling the building.

The woman, who suffered paranoia, needed emergency surgery after breaking her jaw, hip, pelvis and nose in the fall from the roof. 

Avon and Wiltshire Mental Health Partnership (AWP) NHS Trust has since apologised for the incident. In August, the trust was fined £80,000 by magistrates after bosses admitted failing to provide safe care at Sandalwood Court psychiatric hospital.

Now, an internal report on the incident has been published demonstrating AWP bosses knew the low roof was a risk. But it was agreed to manage that risk clinically, with ward staff assessing whether a patient was likely to abscond. The authors of the report, released by AWP following a freedom of information request, said there was a systematic fault.

“The risk was on the health and safety register, it was highlighted annually and escalated trust-wide,” they wrote.

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Source: Swindon Advertiser, 18 October 2019