Norfolk and Suffolk NHS trust fined £366k after 78-year-old patient drowned in hospital bath

The Julian Hospital, Norwic. Photo : Steve Adams Copyright Archant Norfolk

Joan Darnell, who had dementia and bipolar disorder, had been taken from her home in Field Grange, Lowestoft, to the Julian Hospital in Bowthorpe Road, Norwich.

Mrs Darnell, was on the Blickling ward with 15 other elderly patients, with memory problems, when despite being kept under hourly observation by staff, she was able to go into an unlocked bathroom and run a bath and drown, Norwich Crown Court heard.

Saba Naqshbandi, prosecuting on behalf of the Health and Safety Executive, said staff noticed Mrs Darnell missing and a search found her lying face down in a bath on the ward. Despite efforts to revive her, she was pronounced dead at the scene in October, 2014.

Miss Naqshbandi said that the day before Mrs Darnell's death she had been discovered by another member of staff trying to run herself a bath, but no written record had been kept about this incident, although it was reported to a nurse on the ward.

Miss Naqshbandi said that the bathrooms were meant to be kept locked to stop patients wandering in on their own, however since the drowning, automatic locking devices had been fitted to the doors of bathrooms to prevent any future tragedy.

In an impact statement, Mrs Darnell's son Graham described the situation as 'an accident waiting to happen.'

The Norfolk and Suffolk NHS Foundation Trust admitted breaching health and safety regulations by not ensuring the care of Mrs Darnell and was fined £366,000, although the fine was reduced as the court heard that it would have to come out of the under-pressure NHS budget. The trust has agreed to pay the fine by March next year.

Judge Stephen Holt offered his condolences to Mrs Darnell's family and said: 'The day before she was found dead she had been seen by an occupational therapist trying to use the bath.

'On the day of the incident she went missing for some time and staff looked and found her in the bathroom. The problem with these bathrooms was that they did not have an automatic locking mechanism. That situation was changed very quickly after this incident.'

He said that he accepted the trust had no previous convictions and had taken immediate steps to remedy the problems and pleaded guilty at an early opportunity.

Judge Holt also said that as a public body the trust did not have any large reserves or assets and reduced the fine as he accepted a larger fine could inevitably hit services.

Matthew Gowen on behalf of the NHS trust, said that the trust had a good safety record and this was just one ward out of the many run by the trust.

'It delivers a public service 24 hours a day, seven days a week. It does that to the best of its ability.'

He said the trust had co-operated fully with the investigation.

He said there were no national guidelines about locks on bathrooms as each ward had patients with differing capacity.

He said: 'It is quite clear on this particular ward that the policy in relation to locking doors was not uniformly carried out.'

He said there had been issues with the trust in 2014 but since the appointment of new chief executive Michael Scott the trust was no longer in special measures.

After the case Chief Executive for the Norfolk and Suffolk NHS Foundation Trust Mr Scott said: 'Following Mrs Darnell's death we took immediate action to upgrade the locks on bathrooms so they can only be entered into with a key from the outside.'

He said that they also reviewed and clarified the trusts observation policy so staff know what procedures to take when a patient is absent.

'We have also enabled all clinical staff to more effectively evaluate any risk, embedding the enhanced DICES risk assessment training model across the trust.'

He added: 'We have met with Mrs Darnell's family to express our sincere condolences We have also shared our recommendations from our investigation with the family and assured them that all actions have been implemented.'