Scotland's largest health board has been fined almost a quarter of a million pounds after a patient took his own life while in their care.
A father of four, aged 36, died two days after he was admitted to the South Ward at Dykebar Hospital in Paisley on January 22, 2020.
An investigation by the Health and Safety Executive (HSE) found that some of the fixtures and fittings on the ward were not of an anti-ligature design, prosecutors said.
HSE also found failures by NHS Greater Glasgow and Clyde (NHSGGC) in ensuring that the existing ligature points at Dykebar Hospital were suitably and sufficiently risk assessed.
The regulatory body said the health board relied on clinical measures, such as the assessment and observation, rather than physical measures, to ensure his safety.
This is despite NHS-issued guidance requiring risks to be tackled at their source - which should have seen certain taps and ligature points removed or replaced with suitable alternatives.
NHSGGC last month pleaded guilty to a breach of health and safety regulations committed between January 1 and March 23, 2020.
The health board was fined £235,000 with an additional victim surcharge of £17,625 when the case called for sentencing at Paisley Sheriff Court on Monday, the Crown Office and Procurator Fiscal Service (COPFS) said.
Speaking after the sentencing, HSE inspector Lesley Hammond warned that the incident could have been prevented and that the health board failed to live up to their duty of keeping the patient safe.
She said: “The risks presented by access to ligature points in acute psychiatric wards are well known.
“Reasonably practicable measures could have been taken by NHSGGC to reduce the risk to patients, which would have involved the removal of obvious ligature points throughout the ward, as was undertaken after this incident.
“Had a suitable and sufficient risk assessment been in place before the incident and the results acted upon, Mr Donnelly would not have been able to take his own life in the way he did.”
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Debbie Carroll, who leads on health and safety investigations for COPFS, said: “NHS Greater Glasgow and Clyde had a duty to keep their patient safe.
“Had they implemented all reasonably practicable measures they could have prevented him from taking his own life in the way he did.
“Their failure to ensure that ligature points within the hospital were suitably and sufficiently risk-assessed and that patients were not exposed to those ligature points led to the death of a man in their care.
“This prosecution should remind duty holders that a failure to manage and implement effective measures can have fatal consequences and they will be held accountable for this failure.”
Prosecutors said that following the death, remedial work was started but the failings continued until March 23, 2020.
The health board managed the existing ligature risks by placing at risk patients on enhanced observations by nursing staff.
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It claimed that work itself was impacted by the coronavirus pandemic and growing demands on the service.
An NHSGGC spokesman said: “We would once again offer our sincere sympathy to this patient’s family and friends for their loss.
“NHSGGC has identified and commenced a programme of work to remove ligature points.
“Completion of this work was impacted by Covid and by the demands on services, however, it continues and, working within the context of current operational service demands, is being managed to completion.”
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