Under-fire mental health trust Southern Health has pleaded guilty to failing to provide safe care at one of its psychiatric hospitals after a patient suffered serious neck injuries in a fall from a rooftop.
In the first case of its kind, the Care Quality Commission (CQC), which regulates all NHS trusts, has prosecuted the Trust, which has repeatedly hit the headlines over its failure to investigate the deaths of hundreds of patients in its care between 2011 and 2015.
Paul Spencer, representing Southern Health, entered a guilty plea at Basingstoke Magistrates' Court to the offence of failing to provide safe care and treatment and failing to assess risk to patients at Melbury Lodge at the Royal Hampshire County Hospital in Winchester.
Paul Greaney QC, prosecuting for the CQC, said Southern Health had failed to take action to prevent patients from gaining access to the low rooftop between 2010 and 2016.
The case comes after a patient, referred in court as Mr AB, fell from the rooftop in December 2015 and suffered serious neck injuries.
Mr Greaney said: "Between 2010 and 2014, patients who were detained under the Mental Health Act gained access to the roof of the premises or attempted to do so on no fewer than seven occasions.
"The Trust was aware of that dangerous state of affairs but did nothing sufficient to stop it until late April 2016.
"One of the patients who was able to gain access to the roof was Mr AB. He was a patient at Melbury Lodge and, whilst there, he climbed on to the roof, twice slipping and once nearly falling before he was constrained and brought down."
Mr Greaney said Mr AB was discharged, but, after being readmitted in 2014, "his family were worried he might again try to abscond and his wife asked staff to keep an eye on him".
He said that, in December 2015, Mr AB "again climbed on to the roof and, despite attempts by staff to talk him down, he fell to the ground, suffering serious injuries to his neck.
"He survived the fall but with injuries that will affect him for the rest of his life."
Mr Greaney said the Trust did not take action to prevent access to the rooftop until after three more patients had got on to the roof in February 2016 and one suffered minor injuries.
District Judge Philip Gillibrand said Southern Health faced an unlimited fine for the offence.
He said: "It's clearly a case of considerable public interest and concern."
The case was adjourned for sentencing on October 12.
Southern Health released a statement after the hearing, saying: "Southern Health pleaded guilty to the charges from the Care Quality Commission and we are clear that we should have done more to ensure the safety of those under our care.
"We very much regret that injury was caused as a result, and have offered unreserved apologies to the patient involved.
"Following concerns raised by the CQC, our own internal checks and after a comprehensive inspection at Melbury Lodge, anti-roll guttering was installed on the roof in May 2016. We are grateful to the CQC for recognising this work and removing the warning notice of which this risk formed part.
"The safety and well-being of patients is our top priority, and we are continuing a number of programmes of improvement work to ensure that we can deliver safe and quality care across all Southern Health services."