A primary care trust (PCT) has been prosecuted by the Health and Safety Executive (HSE), after a vulnerable and partially-sighted patient fell 4.3 metres from a window while in hospital.

In March 2008 at around 10.20pm, a 68-year-old patient in the St Osyth Priory Ward at Clacton and District Hospital in Clacton-on-Sea, Essex wandered into the ward’s first floor day room and fell from an open window to the ground below.

The window was able to open 254mm – but since 1989, NHS standards have required such windows to open to a maximum of 100mm using a window restrictor. Shortly before the incident, the PCT was required by the Department of Health to review its window restrictors and identify any that were missing, damaged or defective. This review was not carried out.

The retired man suffered a blow to the head and broke his pelvis, shoulder and coccyx in the fall. He was known to wander on the ward and had previously suffered four strokes, which had left him mentally and emotionally impaired.

On Thursday (29/10/09) at Harwich Magistrates’ Court, North East Essex Primary Care Trust of the Colchester Primary Care Centre, Turner Road, Colchester, Essex pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974. The trust was fined £10,000 and ordered to pay costs of £4,972.

After the hearing, HSE inspector Ken Wicks said that the trust had failed in its duty to ensure the health and safety of the retired patient, who was left severely injured after a fall ‘that should never have happened’.

Mr Wicks said the case should ‘serve as an alarm bell’ to remind PCTs of the vital importance of carrying out full risk assessments and acting on the findings.

‘The risk of vulnerable patients falling from windows above ground level is wellknown and there have been a number of similar cases,’ said Mr Wicks.

‘Equally, the control measures – in this case, window restrictors – to prevent this risk are easy to fit and maintain.

‘All PCTs must ensure they adhere to recognised NHS safety standards – they are there for a reason. If North East Essex PCT had done so, this unfortunate incident could have been avoided,’ Mr Wicks added.

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