Health board fined £200,000 after a patient died in its care

Llandudno Magistrates’ Court heard that 46-year-old Dawn Owen was found unconscious at the Hergest Unit - a secure mental health unit - at Ysbyty Gwynedd in Bangor on April 20, 2021.

Dawn’s family have called on Betsi Cadwaladr University Health Board, which cares for patients in North Wales, including Wrexham, to act on the findings of a Health and Safety Executive (HSE) investigation, calling her death ‘wholly avoidable’ and ‘completely unnecessary’.

“Staff complacency at all levels contributed in this case, as well as numerous policy breaches and issues between staff and management,” they said.

“We have been tragically let down by the Hergest Unit, who we believed, were providing a safe place for Dawn and the care that she urgently needed.”

The HSE investigation found no risk assessment had been carried out when she was admitted and due to communication failure on transfer to the ward, staff had wrongly relied on an assessment carried out for a previous admission a year earlier.

This failure resulted in Dawn’s high risk of self-harm being tragically missed.

There were several missed opportunities during the course of the admission, where Dawn had expressed the desire to self-harm. This did not trigger any review of the care and management of the patient.

“Dawn was a highly vulnerable person and had been battling her demons and addictions for many years,” the family went on to say.

“She was a bright, happy person who always had a positive attitude. She had a heart of gold and would always help others in need - she would give away her last penny to do so.

“Betsi Cadwaladr must now act on the findings of this investigation and keep vulnerable patients safe at the unit.

“We hope as a family that Dawn may now rest in peace - her battles with mental health are now over.

“We as a family would like to thank the coroner and HSE for their diligence in ensuring there was a thorough investigation into Dawn's untimely death.”

Betsi Cadwaladr University Health Board pleaded guilty to breaching Section 3 (1) of the Health and Safety at work Act 1974 and was fined £200,000 and ordered to pay costs of £13,174 at Llandudno Magistrates’ Court on Monday.

Speaking after the case, HSE inspector Sarah Baldwin-Jones said: “This incident could so easily have been avoided had a thorough risk assessment been carried out on admission, identifying in this case, the change in Dawn’s condition and risk of self-harm.

“Where a patient presents with a risk of self-harm, there is a requirement upon a health board to manage the patient’s safety, to avoid incidents like this.

"Importantly, the health board should have trained staff in managing this risk in patients considering self-harm.

“This would enable staff to identify the trigger points and take appropriate actions. The health board also failed to monitor the management of patients, so that any patient emotional or behavioural changes can be identified and managed.

“Health boards and trusts should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards. Our thoughts remain with Dawn’s family and friends.”

Betsi Cadwaladr University Health Board chief executive Carol Shillabeer said: “My heart goes out to the family and loved ones of Dawn Louise Owen for their tragic loss. On behalf of the board I wish to reiterate how sorry I am for the failings in her care.

“We are determined to keep improving the safety and experience of the service that we provide, and although the vast majority of patients receive safe and effective care, we will ensure that, where we fall short, that this drives long-lasting change.”

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