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NHS Foundation Trust fined over patient death

A Trust has been fined £30,000 after pleading guilty to breaches of the Management of Health and Safety at Work Regulations and Health and Safety at…

Pennine Care NHS Foundation Trust has been fined £30,000 and ordered to pay costs of £51,223.88 after pleading guilty to breaches of Regulation 3(1) of the Management of Health and Safety at Work Regulations 1999 and Section 3(1) of the Health and Safety at Work Act 1974.

Manchester Crown Court heard how an inpatient drowned during a canoeing activity event at Hollingworth Lake, Rochdale on 5 September 2013.

The inpatient was participating in the pre-arranged canoeing which was provided by an outdoor activities centre in partnership with the Trust, when he removed his buoyancy aid and jumped into the water in an attempt to end his own life.

An investigation by the HSE found that the Trust had failed to carry out a risk assessment for the activity or to adequately assess the inpatient’s suitability to attend.

The deceased’s family said:

"This immensely difficult time, which has now spanned over two years, has left us with no choice but to unfortunately lose trust in the mental health services at Pennine Care NHS Foundation Trust. We cannot help but think that if it was not for these failings then we would still have Mansoor with us today. We hope and pray that some positive changes can come from these events so patients are no longer put at risk."

HSE Inspector Caroline Shorrock said after the hearing:

"The Trust failed to adequately assess Mr Elahi’s suitability to attend the rafted canoeing activity. Mr Elahi’s actions were entirely foreseeable as he had tried to enter the lake on a previous occasion. Had the Trust carried out a suitable assessment they would not have allowed a vulnerable person the opportunity to end his life."