HSE fines NHS provider for a suicide in its care

A healthcare provider, NHS Ayrshire & Arran, has been fined £67,000 by the Health and Safety Executive (HSE) after a patient with a history of depression committed suicide while in its care (Crown Office and Procurator Fiscal Service v NHS Ayrshire and Arran).


  • Mr Gary Niven hanged himself in the Crosshouse Hospital A&E department in August 2010.
  • Mr Niven had called for an ambulance saying that he was feeling suicidal and had already attempted to hang himself. He had a history of depression and intractable cluster headaches.
  • On arrival at the hospital, Mr Niven was taken to a room beside the main staff base where the doors were always left open.
  • Just over an hour after his arrival the charge nurse noticed that the door was closed. Mr Niven was found hanging inside, having constructed a ligature using his jumper.

Findings of the HSE 

It has been rare for the HSE to prosecute healthcare providers over clinical failures. This decision, together with recent Health and Safety Executive action against Mid Staffordshire NHS Foundation, suggests that they are responding to the criticism in the Francis report and are more prepared to look at both non-clinical and clinical failings than they have been. Whether this will change again in light of the Memorandum of Understanding they have agreed with the CQC remains to be seen. The memorandum suggests that where “a patient/service user who did not receive treatment in line with their care plan who died or was severely harmed as a result” it would be for the CQC to consider and decide the action to be taken.


NHS Ayrshire & Arran admitted guilt under section 3 of the Health and Safety at Work etc Act 1974 for failing to ensure the health and safety of people not in its employment. The HSE found that NHS Ayrshire & Arran had identified the risk of psychiatric patients being left alone and had procedures in place but these were not followed.

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