Perth Sheriff Court heard that, between 1 April 2012 and 4 November 2015, on the Moredun Ward at general adult psychiatry ward of Murray Royal Hospital, Perth, three patients were able to utilise ligature points to take their own lives. Patients on Moredun Ward are acutely unwell and often not in a position to ensure their own safety.

An investigation by the Health and Safety Executive (HSE) found that Tayside Health Board failed to assess, manage and control the risk of severe injury and death associated with ligature anchor points. 

Private bedrooms within the facility had multiple ligatures points which could have been removed to reduce the risk to patients on the ward. The health board failed to effectively communicate risks associated with the ligature points to staff who were required to monitor and assess patients. A previous attempt by one patient to secure a ligature to a ligature anchor point was not communicated to the staff who monitored her. She later successfully took her own life by the same method.

Tayside Health Board pleaded guilty to breaching Sections 3(1) and Section 33(1)(a) of the Health and Safety at Work Act and was fined £120,000.

After the hearing, HSE inspector, Kerry Cringan said: “These tragic incidents led to the avoidable deaths of three women. These deaths could have been prevented if the Health Board had acted to ensure their ward met the required standards for acute mental health facilities. 

“This requires providers to ensure that spaces where service users are not continually supervised are designed, constructed and furnished to make self-harm or ligature as difficult as possible. HSE will not hesitate to take appropriate enforcement action if providers fail to meet these standards.”