Health Board fined after patient death and Improvement Notice non-compliance


A Health Board has been fined following the death of a vulnerable patient who left a hospital ward unnoticed through an unsecured door.

The HSE’s investigation concluded that Cwm Taf Morgannwg Health Board failed to act on previous absconding incidents, which would have better protected 74-year-old Lynwen Thomas, who went on to fall in icy conditions in the hospital grounds and suffer a fatal head injury.

On 13 November 2019 Mrs Thomas, a patient on Llynfi Ward at Maesteg hospital, who was a known wanderer, left the hospital after 8pm unnoticed by hospital staff. That evening was very cold with snow on the ground. Mrs Thomas fell on a path resulting in her fatal injury.

The HSE found that despite previous absconding incidents, including one involving Mrs Thomas, no reasonably practicable measures were taken at Llynfi Ward until after the fatal incident to protect vulnerable patients from wandering and potentially coming to serious harm.

Following another patient absconding incident at Princess of Wales Hospital, the HSE served an Improvement Notice on the Health Board on 30 September 2020. The Notice applied to the Bridgend locality and required the Health Board to assess the risk to patients from escaping, absconding or wandering. The Notice was not complied with by the due date.

Before Cardiff Magistrates’ Court, Cwm Taf Morgannwg Health Board pleaded guilty to charges of breaching Section 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974 and were fined £850,000 with full costs awarded of £10,627.30

Speaking after the hearing, HSE inspector Helen Turner, said: “Lynwen Thomas was a vulnerable patient, and known to abscond. Cwm Taf Morgannwg Health Board had a duty to protect her and other patients on Llynfi Ward, and they failed to identify or act on absconding risk.

“Despite significant warnings, there was no risk assessment or physical security measures introduced to prevent vulnerable patients from leaving the ward unnoticed. This incident was easily preventable and the risks should have been identified.”


HSE July 2022

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