The Health and Safety Executive (HSE) has commented on the failure of an NHS Foundation Trust in taking adequate care of an inpatient with mental health issues, during a pre-arranged canoeing activity event.

HSE Inspector Caroline Shorrock said: “The Trust failed to adequately assess… the patient’s suitability to attend the rafted canoeing activity… Had the Trust carried out a suitable assessment they would not have allowed a vulnerable person the opportunity to end his life.”

The patient removed his buoyancy aid and jumped into the water at Hollingworth Lake in Rochdale. An investigation by the HSE found that Pennine Care NHS Foundation Trust had failed to carry out a risk assessment for the activity or to adequately assess the patient’s suitability to attend, despite running the activity for 2 years.

Not only should a risk assessment of the activity been completed, but due to the health of the patients participating in the event, a risk assessment of each patient should have also been completed on an individual basis.

The actual activity was also poorly monitored by appropriate mental health practitioners- the only appropriate practitioner on attendance stayed on the shore during the activity, with another patient who was unwell and could not participate.

The Trust pleaded guilty to breaches of Regulation 3(1) of the Management of Health and Safety at Work Regulation 1999 and Section 3(1) of the Health and Safety at Work etc. Act 1974 and was heavily fined.

This tragic case of poor (or indeed no) risk assessment which lead to the death of an inpatient could have been avoided. A duty of care is owed to in-patients, even on day trips when they are out of their usual environment.

How can we help?

If you or someone you know has been injured as a result of poor risk assessment, contact Ringrose Law. Call in at one of our offices in Boston, Lincoln, Grantham, Sleaford, Newark or Spalding and ask to speak to a member of the Personal Injury Team.

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