AKM Fabrications


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  • Ordnance Way, Buckshaw Village
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Need for hospital guardrails highlighted by incident


An incident at a hospital mental health ward has highlighted the importance of guardrails on elevated positions around hospital grounds.

Lincolnshire Partnership NHS Foundation Trust has been fined following the incident at Boston Pilgrim Hospital’s Ward 12, which occurred in March 2013.

A 26-year-old man was detained under the Mental Health Act, but despite a history of self-harm, was allowed outside to smoke.

He twice evaded staff and managed to scale a single-storey building, but was talked down – but on a third occasion, he jumped from the roof and was paralysed in the fall.

An investigation found that several previous incidents of patients scaling the roof had been recorded, yet no risk assessments had been conducted to determine the potential for self-harm acts to be committed in the area.

“The necessary level of control needed to protect him from harm had not been achieved,” said HSE inspector Lyn Spooner.

“As a result, he gained easy access to a roof, dived off and suffered life-changing injuries.”

The incident is a reminder of the importance of guardrails for any elevated position where public or patient access may be possible, to prevent such injuries from occurring in the future.