Cwm Taf Morgannwg fined £850k after Maesteg patient death
- Published
Lyn Thomas was the "loving and kind heart of our family".
A health board has been fined £850,000 after a patient fell in the grounds of a hospital and died from her injuries after wandering from an unlocked ward.
Lyn Thomas, 74, died in November 2019 while at Maesteg Hospital recuperating after a brain operation.
Her son Andrew said it was "beyond belief" she had been allowed to wander out on different occasions.
Cwm Taf Morgannwg health board admitted offences under the health and safety at work act.
Mr Thomas, in a statement to Cardiff magistrates, said his mother was the "loving and kind heart of our family".
Lyn Thomas was staying on the Llynfi ward at Maesteg Hospital which cares for elderly patients and those with dementia to recuperate after surgery at the University Hospital of Wales (UHW) in Cardiff.
A Deprivation of Liberty Safeguarding order (DOLS) had been in place in hospital in Cardiff because of her confusion following the operation and her risk of wandering, the court heard.
But at the hospital in Maesteg, no DOLS order was initially put in place and no risk assessment was made.
The court heard that the Llynfi ward in Maesteg had no lock on the door that prevented patients from leaving. The day after Mrs Thomas was admitted to the ward, she was found outside on her knees at a nearby bus stop.
As a result an urgent DOLS order was put in place. Despite this Mrs Thomas was found wandering the grounds in the following days.
On 13 November 2019, Mrs Thomas left the ward unnoticed once more just before 8pm.
Lyn Thomas left the hospital several times after being admitted to the Llynfi ward at Maesteg Hospital
She left the hospital by the front door. Around 20 minutes later she was found on the ground near the gateposts with serious head injuries.
'Beyond belief'
She had crossed a zebra crossing and gone down external steps. It was dark and wet and there was snow on the ground.
The court heard that Mrs Thomas's condition deteriorated rapidly and she died.
In a statement read to the court, her son Andrew Thomas also felt that in Maesteg "the staff were not as caring or involved with us as they were at the UHW".
He said it was "bad enough" that his mother had managed to get outside within a day of arriving in Maesteg. He said it was "beyond belief" that it happened on two further occasions.
The court also heard that following later inspections by the HSE, the health board was served an improvement notice in October 2020. The board also admitted that the improvements were not made within the timescale required.
Cwm Taf Morgannwg's barrister Nigel Fryer told the court that the board apologised "wholeheartedly and profoundly to the Thomas family".
He said the "board had been horrified by what had happened and there were failures".
We have put in place critical improvements to prevent such a tragic event happening again
The Llynfi ward remains closed pending a full assessment.
The court heard that there had been previous incidents of patients absconding from the ward. Mr Fryer said "the lock was obvious, it would be trite and foolish to accept anything else".
The court was told that a lock was put on the door of the ward within 24 hours of Mrs Thomas's death.
Helen Turner, HSE inspector, told BBC Wales there were no measures to stop vulnerable patients from leaving and the health board "fell very far short" of what needed to be in place.
She said the case was about accountability and responsibility.
"It's about managers recognising risk and taking action for things within their level of control," Ms Turner added.
She said the health board was working hard to change the culture and hoped the prosecution would send a strong message to health boards across Wales.
Chief executive of Cwm Taf Morgannwg, Paul Mears said: "As a health board, we fully accept the charges brought against us in this case and take this opportunity to reassure Mrs Thomas' family, and those in our wider communities, that we have put in place critical improvements to prevent such a tragic event happening again.
"At Cwm Taf Morgannwg we are committed to putting things right and to providing the very best healthcare services our communities deserve.
"We have taken the learning from Mrs Thomas's tragic death and I have confidence in the robust risk assessments, policies and procedures now in place across all of our inpatient areas."
- Published10 February 2022
- Published17 May 2022
