Segurança do paciente
Hospital multado após morte de paciente. Ele caiu pela janela do quarto. O problema que permitiu a queda já havia sido alvo de recomendação de segurança.
O caso tem interesse especial também na área jurídica. Diferenças na regulação entre diferentes países pode explicar desfechos diferentes. Mas a existência de políticas e práticas de segurança do paciente, o foco dada a essa questão atualmente no Rein Unido (e que é crescente também aqui no Brasil), também ajuda a entender o caso.
PB
NHS trust fined following patients death
Date:
25 November 2016
A South West NHS trust has been fined £200,000 after a patient fell to their death from a window.
Bristol Crown Court heard how Mr Mark Scott-Green, an in-patient on the hospital’s Haygarth Ward, had become confused and vulnerable while staying at the facility.
The Trust authorised a Deprivation of Liberty Safeguard, which allowed them to forcibly return patients to their rooms for treatment in their best interest. On the 17 November 2012 hospital security had returned Mr Scott-Green to his room, he was later found on the lying in the courtyard having fallen from his second floor window.
An investigation by the Health and Safety Executive (HSE) found the ward’s window was only fitted with one restrictor. The window was large enough to flex and the gap measured after the incident was larger than the recommended 100mm standard. It was also discovered other windows on the same ward and across the Trust were not adequately restricted.
A safety alert had been previously issued by the Department of Health to all NHS Trusts informing them of the risks of relying on just one window restrictor. Following the incident the Trust were issued with an HSE Improvement Notice to ensure all the restrictors were suitable and prevented the windows opening more than 100mm.
Royal United Hospital (Bath) NHS Foundation Trust, Coombe Park, Bath, pleaded guilty to breaching Section 3 (1) of the Health and safety at Work Act 1974 was fined £200,000. Costs will be decided at a hearing on 19 December.
HSE inspector Stephan Axt-Simmonds said, “Hospitals must take into consideration the confused mind-set of some vulnerable patients when carrying out risk assessments. On this occasion the Trust had already received clear guidance that a single restrictor was not suitable, but ignored the advice.”
Notes to Editors:
The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice, promoting training; new or revised regulations and codes of practice, and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
More about the legislation referred to in this case can be found at: www.legislation.gov.uk/ link to external website
HSE news releases are available at http://press.hse.gov.uk
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