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NHS Trust Fined After Dementia Patient Absconded and Died

An English NHS trust has been fined for 'unacceptable' care failures, which saw a dementia patient abscond from a hospital three times and die after injuring his head in a fall.

University Hospitals of Derby and Burton NHS Foundation Trust has been ordered to pay a total of £216,664.88 after pleading guilty to failing to provide safe care and treatment to a male dementia patient, causing him avoidable harm, following a sentencing hearing at Derby Magistrates' Court on Monday, 20 March.

The Care Quality Commission (CQC) brought the prosecution following an incident in July 2019 when Peter Mullins, a patient with advanced dementia, was admitted to Queens Hospital Burton emergency department. He absconded from the emergency department twice, and after a third time trying to abscond was followed by staff.

However, despite being followed he was still able to climb over a barrier and fall down a grass bank hitting his head on concrete at the bottom. He was airlifted to the local trauma centre, but sadly died of multiple traumatic injuries.

The trust pleaded guilty to the offence of failure to provide safe care and treatment to Mr Mullins, for which it was fined £200,000. The court also ordered the trust to pay a £181 victim surcharge and £16,483.88 costs to the CQC.

'Unacceptable' Failure to Manage Patient Safety 

Lorraine Tedeschini, CQC's director of operations in the midlands, said: "This is a tragic case and my thoughts are with Peter's family and others grieving for his loss following his death.

"People have the right to safe care and treatment, so it's unacceptable that his safety was not well managed by University Hospitals of Derby and Burton NHS Foundation Trust .

"We know that the majority of people receive good care when they attend hospital, but if we find a provider has put people in its care at risk of harm, we take action to hold it to account and protect people in future.

"I hope this prosecution reminds health and social care organisations they must provide care in a safe environment that meets the needs of patients, so they receive the safe care and treatment they deserve."

Trust 'Committed to Improving Care'

In a statement issued to the media following the court case, Garry Marsh, executive chief nurse for University Hospitals of Derby and Burton NHS Foundation Trust, said: "We remain incredibly sorry for what happened to Mr Mullis, and our sincere condolences continue to be with his family.

"Mr Mullis was supervised during his time in our care but it is clear that improvements were needed to how some of our polices, there to keep people like Mr Mullis safe, were put into practice and we fully accept the CQC's findings.

"Since this sad incident in 2019 we have created a dedicated Mental Capacity Act education team to better support and train our staff, and introduced a new auditing process to track compliance against best practice. We remain absolutely committed to improving further to ensure that we provide the safest care and treatment to all patients in our care."

Since the incident, the trust said it has taken a number of steps to improve care, including:

  • Dementia specialists have delivered, and continue to deliver, training to staff about the Enhanced Care Bundle, a behaviour assessment tool, to help better identify the type of enhanced care and supervision required for an individual patient. 
  • A Mental Capacity Act improvement group has been established
  • Audits are carried out quarterly to monitor compliance, and are reported through formal governance processes. 
  • The Trust's Mental Capacity Act training programme has been reviewed, and will continue to be enhanced in line with current best practice. 
  • The emergency department triage process at Queen's Hospital Burton now formally includes Mental Capacity Assessment. Compliance is audited. 
  • A wooden fence has been put in place in the outdoor area where the fall sadly occurred.
  • All ward doors have a button that must be pressed (by staff, visitors or a patient) in order to exit the ward.