18th Jun, 2021 Read time 1.5 minutes

NHS Trust fined after lack of control measures over environmental risks

The Essex Partnership University NSH Foundation Trust has been fined for failing to manage the environmental risks associated with the mental health inpatient wards.

Chelmsford Crown Court heard that between 2004 and 2015 the trust had failed to manage the environmental risks of fixed ligature points within the mental health inpatient wards. Eleven inpatients died during this time period whose deaths involved access to fixed ligature points.


The environmental risks were not addressed


After an in-depth investigation by the HSE Executive, it was determined that the trust had failed to identify and adequately manage the risks of the fixed ligature points within the ward.

The failure to address the risks led to patient deaths and is a reminder of why we must always address safety concerns no matter what context they are in.

Essex Partnership University NHS Foundation Trust of The Lodge, Lodge Approach, Runwell Wickford, Essex pleaded guilty to breaching Section 3(1) Health and Safety at Work Act 1974. The Trust was fined £1,500,000 and ordered to pay costs of £ 86222.23.



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"It has long been recognised that a key control in the prevention of inpatient death or self-harm is the identification and removal of potential fixed points of ligature from the ward environment. For a period of more than 10 years, NEPUFT repeatedly failed to manage these well-documented risks, including learning from tragic experience, thereby needlessly exposing vulnerable patients in its care to unacceptable risk.

: HSE Inspector Dominic Elliss"

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