NHS Foundation Trust Fined Over Patient Death Following Failure to Risk Assess Activity


01 September, 2016

Pennine Care NHS Foundation Trust has been fined for safety failings after a patient drowned during a canoeing activity event.

Mr Elahi, who was an inpatient at Birch Hill Hospital was participating in a pre-arranged rafted canoeing activity provided by an outdoor activities centre in partnership with Pennine Care NHS Foundation Trust, when he removed his buoyancy aid and jumped into the water in an attempt to end his own life.

An investigation by the Health and Safety Executive found that Pennine Care NHS Foundation Trust had failed to carry out a risk assessment for the activity or to adequately assess Mr Elahi's suitability to attend.

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

HSE Inspector Caroline Shorrock said: "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."

Forbes comment

It is crucial that social clubs, summer clubs, schools and public authority functions carry out thorough written risk assessments when undertaking activities involving young vulnerable adults or children. As demonstrated in this case, a failure to do so can have fatal consequences.


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