Gov fined £80k after patient jumps from Orchard House roof

Friday 26 March 2021

The Government has been fined £80,000 after a suicidal patient jumped off the roof of Orchard House - just 18 months after the Health Department was warned to make changes to the mental health facility to avoid such incidents.

The patient suffered serious injuries, including multiple broken bones, after falling two storeys onto the tarmac below last May.

The States Employment Board (SEB) - which is responsible for health and safety matters on Government premises - appeared in the Royal Court for sentencing this afternoon after admitting its failure to "take adequate steps to provide a safe environment for the treatment of patients that prevented, so far as is reasonably practicable, vulnerable people from accessing the roof area at Orchard House where they may be exposed to risk."

Following the sentencing, SEB Vice-Chair Constable Richard Buchanan said the board had offered "sincere and unreserved apologies to the patient and family for the injuries sustained".

“The SEB have acknowledged that the incident was avoidable and we are genuinely remorseful that the patient sustained injuries in an establishment which is there to keep [them] safe,” he added. 

Pictured: Connétable Richard Buchanan, the Vice Chair of SEB.

“We have met the management of the unit, who have taken us through the significant improvements made to the physical environment and staff training since this unfortunate incident. 

“I again offer our apologies to the patient and [their] family." 

Summing up the facts for the prosecution, Crown Advocate Matthew Maletroit said the SEB's failure to protect patients from accessing the roof at Orchard House came "despite a health and safety assessment requiring remedial action to address that risk" and three other patients previously managing to access the roof area.

“As a consequence, a suicidal patient managed to access the roof and jumped from second storey height onto a tarmac surface, sustaining serious injuries," he said.

The patient was admitted to Orchard House just 10 days before the incident after having shown suicidal ideation and accessing the roof of another property before “changing [their] mind and safely returning to the ground”.

Pictured: The patient had been admitted at Orchard House just 10 days before the incident.

Two days after their admission, the patient tried to harm themselves while on the ward, leading staff to raise their levels of observation so that the patient would always be within the eyesight of a member of staff. 

On the day of the incident, those levels had reduced, and the patient was only checked every 15 minutes. 

They left the ward by a door which should have been locked with an electronic lock and a physical lock to prevent patients leaving the ward unaccompanied. However, on the day of the incident, it was left propped open with a flowerpot due to the warm weather.

The Court heard that patients were supposed to always be supervised by a member of staff when they used the garden.

The patient, which was captured on CCTV, climbed a fence to access the roof before jumping from about two storeys above the ground onto the tarmac below, suffering what the Crown Advocate described as “serious injuries”.  

Pictured: The Health Department had been told to erect an anti-climb perimeter fence by October 2018.

The Court heard that, following a risk assessment in 2018, the Health and Safety Inspectorate had told the Health Department that an anti-climb perimeter fence should be erected by October 2018 - but one still wasn't in place 18 months later by the time of the incident.

The risk assessment also noted that access to low-lying buildings should be restricted and the SEB said the “erection of plywood around the perimeter of the edge” had achieved that. 

The SEB admitted that the policy of keeping the garden access door shut had not been written down but was instead verbally disseminated among members of staff.

The Board also admitted there had been three previous incidents when patients had gained access to the roof.

In his conclusions, the Crown Advocate moved for a £100,000 fine describing the case as more serious than previous health and safety breaches by the SEB due to the risk of harm being more serious and the “serious aggravating feature” of the board being aware of the risk of patient accessing the roof, an issue which had been identified in 2018 and demonstrated by previous incidents where patients accessed the roof.

Pictured: Advocate Corbel argued that the fine suggested wasn’t “rationalised in any way” and had been selected “without a basis”.

Representing the SEB, Advocate Debbie Corbel presented the SEB’s “unreserved apology to the patient and their family for the incident."

She went on to say that, while the SEB had acknowledged its duty as employer, it was not responsible for providing the Orchard House facility, for which the Government was responsible along with funding decisions about its improvement.

She said that, since the incident, improvements had been made to Orchard House as part of a £630,000 investment in facilities.

She added that while safety systems were already in place at the time of the incident they were now used “much more thoroughly” and “carefully documented”. 

Advocate Corbel argued that the fine had been selected “without a basis”, noting: “It is wholly out of quilter with the authorities that are said to being relied upon."

She also told the Court that the fact the fence hadn’t been erected was neither part of cost-cutting nor “a deliberate attempt to avoid expenditure”. 

Pictured: The case was heard by the Bailiff, Timothy Le Cocq, sitting with Jurats Collette Crill and Pam Pitman.

The case was heard by the Bailiff, Timothy Le Cocq, sitting with Jurats Collette Crill and Pam Pitman.

When returning their sentence, the Bailiff said “full remedial action” had been taken to address the risks highlighted by this and other incidents. 

He described the incident as the result of “serious failings in light of previous warnings”. 

The Court agreed with the Crown Advocate that the SEB’s culpability was “high” and imposed a £80,000 fine. They also ordered the SEB, which was represented by Mark Grimley, the Government’s Group Director of People and Corporate Services, and Constable Buchanan, to pay £5,000 towards the prosecution costs.