Huge fine for NHS Health Board failings that led to a man’s death

An incident involving a man who took his own life whilst in the care of NHS Greater Glasgow and Clyde (NHSGGC) has prompted investigators to look into the health board’s health and safety failings.

Martin Donnelly, 36, had been medically detained at the South Ward of Dykebar Hospital in Paisley. He was known to have a history of mental illness and had been staying at the ward for two days beforehand in January of 2020.

Investigating the incident, the Health and Safety Executive (HSE) found that the NHSGGC had failed to ensure a suitable risk assessment, meaning that only clinical control measures were in place to protect patients. This meant that physical ligature points were not identified and were subsequently used by Mr Donnelly to end his own life.

HSE discovered that reasonably practicable measures were not taken by NHSGGC, which could have prevented Mr Donnelly from taking his own life.

NHSGGC pleaded guilty to breaching sections 3(1) and 33(1)(a) of the Health and Safety at Work etc. Act 1974 on the 30 June 2023. At a hearing on 10 July 2023, the health board was fined £235,000 and ordered to pay a victim surcharge of £17,625.

Speaking after the sentencing, HSE Inspector Lesley Hammond said: “The risks presented by access to ligature points in acute psychiatric wards are well known.

“Reasonably practicable measures could have been taken by NHSGGC to reduce the risk to patients, which would have involved the removal of obvious ligature points throughout the ward, as was undertaken after this incident.

“Had a suitable and sufficient risk assessment been in place before the incident and the results acted upon, Mr Donnelly would not have been able to take his own life in the way he did.”

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