Queen’s Hospital Burton fined over £200k after patient absconded, fell and died
University Hospitals of Derby and Burton NHS Trust (the “Trust”) have accepted the findings and pleaded guilty to failing to provide safe care and treatment.
The Trust admit to exposing a patient to a significant risk of avoidable harm.
The Trust has been fined £216,664.88 for failing to look after a dementia patient who absconded and died.
The patient, Peter Mullis, was a clear escape risk having absconded from Burton Hospital two times prior to the incident. Mr Mullis was labelled as a bit of an “escape artist.” It was while on the acute assessment ward that Mr Mullis made his third and final attempt to escape. Two nurses chased after him and security was called but in response to being followed, he threatened to punch any staff that came close. Mr Mullis reached a metal barrier that was only 3ft (1m) high, the obstacle had been temporarily put in place to stop people using it as a cut-through. Once over the barrier Mr Mullis ran down the grass verge, lost his balance and fell down the slope, hitting his head on the concrete pavement at the bottom. The patient was air lifted to Royal Stoke University Hospital’s trauma centre but suffered a catastrophic head injury and died later that day.
The prosecutor on behalf of the Care Quality Commission (CQC), Mr Khokhar found that University Hospitals of Derby and Burton NHS Foundation Trust failed to take all reasonable steps to ensure safe care. This traumatic incident was a result of not just one, but a “catalogue of failures.”
The CQC’s findings noted that the Trust’s ‘missing patient policy’ was insufficient, “there were inadequate levels of training which could have been addressed earlier.”
Where the responsibility lay, a care plan should have been put in place immediately following the first attempt to abscond.
A victim impact statement from Mr Mullis’s daughter, Selina Kendrick told us how her father had a difficult time in 2018 where he was struggling with his mental health and moved from homeless accommodation to a warden-controlled nursing home.
Nearly four years on, his death is still raw for her, she feels she has been “robbed of getting to know her Dad again,” due to the Trust’s failure to implement “basic safeguarding.”
Eleanor Sanderson, for the University Hospital for Derby and Burton NHS Foundation Trust said in mitigation that the slope was often used as a walkway and whilst Mr Mullis’s fall was tragic, the death had been unlikely and unpredictable. She goes on to reassure the public that “the trust has done everything it can to ensure that such an event does not happen again.”
Since this sad incident in 2019, the Trust have put in place a dedicated Mental Capacity Act education team to better support and train staff and introduced a new attuiting process to track compliance against best practice. The Trust have erected a wooden fence in the outdoor area where the fall happened, and all ward doors are fitted with a safety button that must be pressed in order to exit.
Garry Marsh, Executive Chief Nurse for University Hospitals of Derby and Burton NHS Foundation Trust, said: “We remain absolutely committed to improving further to ensure that we provide the safest care and treatment to all patients in our care.”
If you have any queries on the topics of this article, get in touch with Demi Shephard.
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